Peace Corps MTG 605 FOIA General Medicine Nurse

Peace Corps
Technical Guideline 605

TREATMENT PROTOCOLS AND STANDING ORDERS FOR REGISTERED NURSE (RN) PCMOS
1. PURPOSE
To provide guidance for registered nurse (RN) Peace Corps Medical Officers (PCMO) in the
utilization of treatment protocols. These protocols will assist the RN PCMO in providing
clinical care within the scope of their practice.
2. BACKGROUND
The scope of practice for RN PCMOs in Peace Corps countries is aligned with the Electronic
Community Health Aide Manual (eCHAM). The Electronic Community Health Aide Manual
(eCHAM) has been chosen to assist RN PCMOs with performing basic consultation,
comprehensive nursing assessment, nursing diagnosis and documentation and medical
treatment. Certain Peace Corps Medical Technical Guidelines (TGs) cover common health
issues that may arise during Peace Corps service, and are not found in the eCHAM (for
example: Tropical Disease assessment and management). The TGs and the eCHAM provide
the RN PCMOs the basis to perform comprehensive assessment and care that is in line with
current best practices.
3. ELECTRONIC COMMUNITY HEALTH AIDE MANUAL (eCHAM)
The eCHAM reflects best practice recommendations for rural health care delivery and thus
has been adopted for use by Peace Corps clinical programs as best practice for care
delivered to Volunteers.
Any provider working with Peace Corps registered nurses must be familiar with the Peace
Corps Scope of Practice for Professional Nurses (TG 114) and the Electronic Community
Health Aide Manual (eCHAM) because:
Registered nurses are trained to follow the eCHAM for all patient encounters.
The eCHAM contains patient care plans that the Director of the Office of Medical
Services (D/OMS) approves as standing orders, allowing an RN PCMO to manage
designated condition specific patient problems without contacting the prescribing
physician.
The eCHAM provides a framework that registered nurses use to understand
other instructions from physicians.
Peace Corps Technical Guidelines and Scope of Practice direct registered nurses to
use the eCHAM as reference for all for patient care encounters.
The RN must be flexible and use good clinical judgement; at times there must be
changes to what is done and how one does it. This being said, the RN may not change
the plan (and thus, the standing order) without consulting the prescribing physician.
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4. MEDICAL TECHNICAL GUIDELINES (TGs)

The Medical Technical Guidelines (TGs) provide a framework for management of the medical
Unit as well as condition-specific protocols which give clinical guidance for treating
Volunteers. The TGs are continuously updated and amended to cover topics that are useful
for providing clinical care and support to the Volunteer population.
The D/OMS approves designated condition-specific TGs as standing orders for RN PCMOs,
thereby allowing an RN PCMO to manage certain patient problems without contacting the
prescribing physician. As with the eCHAM, the RN PCMO may not change the plan (and thus,
the standing order) without consulting the prescribing physician.
5. MEDICAL SUPERVISION
It is the D/OMS who provides medical oversight that enables the RN PCMO to practice using
these protocols. The Office of Health Services, through the D/OMS is responsible for
supervision, direction and support for the registered nurses in a number of different ways.
The authorization allowing the RN PCMO to treat a Volunteer may be given:
a. Directly:
Through reporting the patient encounter to the supervising physician or that
physicians designee. Example: Physician PCMO, Physician Assistant PCMO, Nurse
Practitioner PCMO, or a community back-up provider.
b. Indirectly:
Through a standing order which allows the RN PCMO to follow the eCHAM
protocol, TGs or other Peace Corps approved protocols without consulting the
physician.
c. When the protocol says Report to your referral doctor, the RN PCMO must follow
Peace Corps guidelines and report to the local prescribing provider (as designated by
the D/OMS) or if unavailable, to the D/OMS or designee.
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6. RESPONSIBILITIES OF THE RN PCMO

Responsibilities of the RN PCMO include:
Provide patient care to the Volunteer:
- Emergency
- Acute
- Chronic
- Preventive
Work collaboratively with the other members of the health care team
Maintain confidentiality regarding patient care
Manage the clinic, as appropriate to the post, according to Peace Corps guidelines
Be familiar with the Electronic Community Health Aide Manual (eCHAM):
- Use the eCHAM for each patient encounter
- Document (record) each patient encounter thoroughly using SOAP note format.
Be familiar with the Medical Technical Guidelines
- Use the TGs for the applicable condition-specific treatment after an assessment
has been made by following the eCHAM for the patient encounter.
Be familiar with the PCMO Registered Nurse Scope of Practice as outlined in TG114
Seek advancement in training
Be in compliance with continuing education, licensing and credentialing requirements
Be familiar with the local clinic operations:
- The local culture and how it might impact health issues and care
- Personnel and resources available
- Equipment available and its proper use
- Understand and follow the reporting and referral process
- Participate in a quality assurance process
Be familiar with Peace Corps system of medical supervision:
- Who provides medical supervision?
o Director, Office of Medical Services (D/OMS)
- When does the RN report patient encounters?
o As directed in TG/eCHAM
- Who does the RN clinical skills evaluations?
o The Quality Improvement Unit with input from RMOs and D/OMS
- Who assigns appropriate standing orders?
o The D/OMS
7. RESPONSIBILITIES OF THE OFFICE OF HEALTH SERVICES
Provide training and assistance to registered nurses in clinic setting:
a. Conduct routine chart reviews to ensure compliance
b. Promote clinical competence (through in-service education, CME, oneon-one teaching, mentors, etc.)
c. Assess clinical competence
d. Provide consultation regarding skills and standing orders
e. Monitor and provide continuing education
f. Maintain nurse credentialing and certification requirements and expirations
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8. RESPONSIBILITIES OF THE DIRECTOR/OFFICE OF MEDICAL (D/OMS) SERVICES OR DESIGNEE

The responsibilities include:
a. Provide medical supervision and support to RN PCMOs
b. Respond to registered nurse calls and contacts promptly through the field support
system
c. Be familiar with Peace Corps health unit operations
d. Maintain and adapt as necessary the Peace Corps standing orders and protocols
e. Maintain subscription to the Electronic Community Health Aide Manual (eCHAM)
and facilitate access for RN PCMOs
f. Maintain and adapt as necessary the Medical Technical Guidelines (TGs)
9. STANDING ORDERS
Medical supervision is essential to the success of the Peace Corps clinical protocols and
standing orders. The following provides additional information about standing orders,
as an alternative to the registered nurse reporting every patient encounter as it occurs.
The RN PCMO with training and experience can follow the eCHAM and TGs protocols,
and their relevant standing orders to provide care for routine health issues without
contacting the doctor for every patient encounter, therefore the RN PCMO can practice
more effectively and efficiently. Standing orders for straightforward, routine care
reduce demand on the physicians time and can provide for more efficient delivery of
health care to Volunteers.
a. Physician initiated standing orders authorize RN PCMOs to treat a patient by
following specific patient care plans as written in the Electronic Community
Health Aide/Practitioner Manual(eCHAM), or Peace Corps Medical Technical
Guidelines without consulting the referral doctor.
b. RN PCMOs must request standing orders at the time of privileging
i. The D/OMS grants standing order privileges based on demonstrated and
reported competencies.
c. Plans with possible standing orders
i. The eCHAM includes the option of allowing a RN PCMO to be granted
standing order privileges for certain health problems where competency
has been proven through education or experience.
ii. Plans for which the eCHAM provides a possible standing order are
indicated after the plan title with: Standing Order Possible. These are
usually common, straightforward problems, where reporting is not
likely to change the assessment or plan. That is, the physician probably
would not come to a different conclusion if the RN reported verbally or
sent in a patient encounter form.
d. Changes to standing orders
i. RN PCMOs must request any desired changes or variations from the
D/OMS using the Change to Standing Order in the CHAM or Technical
Guideline form (TG 605 Attachment E).
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e. Patient Specific Standing Orders (PSSO)

i. Patient Specific Standing Orders (PSSO) provide a mechanism for RN PCMOs
to monitor and refill prescriptions for patients (PCVs) on chronic medication.
The orders can be approved by PCMO colleagues at post (Form TG 605C); if no
PCMO colleague is assigned to post the RN PCMO submits the orders (Form TG
605D) to the QIU for review who then submits to the D/OMS for signature.
ii. Patient Specific Standing Orders reduce the potential for error and free up
the prescribing provider from having to be the only one monitoring and
dispensing.
f. Verbal Orders
i. RN PCMOs can accept orders for acute treatment from any licensed
provider (physician, NP, PA, dentist, podiatrist etc.). These orders must be
noted as verbal/telephone order and should be signed by the prescribing
provider at the earliest convenience.
10. STANDING ORDERS OVERVIEW
The plan in the eCHAM or TGs is the condition-specific standing order
Condition-specific plans with possible standing orders may contain an
ALWAYS Report caution, which safeguards those patients who may be more
complicated (Examples: Volunteers with multi-system disease, or PCVs with
more concerning symptoms). These patients would not be covered by the
standing order, and the RN PCMO would actively consult the referral doctor
(prescribing provider).
If there is no eCHAM plan for a certain condition the D/OMS may approve a
Peace Corps specific plan from the TGs (Example: TG 845 Malaria Diagnosis
and Treatment).
If a different treatment plan is created; it must be clear which instructions the RN is
to follow. Any new plan:
- Must be plainly written (preferably in a format similar to the eCHAM)
- Must be signed by the supervising physician (D/OMS or designee).
- Must be on file at Peace Corps headquarters and the RNPCMO
Health Unit
Patient-specific Standing Orders for chronic medication refills and monitoring may be
granted by the prescribing physician at Post as designee of the D/OMS (TG 605
Attachment C).
A. Granting Standing Order Privileges
Only the D/OMS or designee who must be a licensed physician employed or
contracted by the federal government can grant RN PCMO standing orders
The Credentialing Committee recommends to the prescribing physician what skill
level the RN PCMO is at and if he/she has met the requirements of the organization
which would allow the RN PCMO to practice using standing orders
RN PCMOs practice under the medical authorization of the supervising
physician (D/OMS or designee)
Standing orders authorizing the RN PCMO to follow the eCHAM treatment
plan (or other written guideline, including TGs), without consulting a
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physician are granted by the D/OMS.

B. Criteria for Granting Standing Orders
To grant a standing order, the supervising physician must have sufficient knowledge
of this RN PCMOs clinical skills and ability to:
- Use the eCHAM to obtain a thorough history
- Perform an adequate exam, and recognize and describe abnormal findings
- Use the eCHAM to arrive at an accurate assessment
- Follow the eCHAM plan without needing further direction
- Recognize the patients who are exceptional and need to be reported,
even with a standing order
The physician responsible for granting standing orders will receive evaluation of the
RN PCMOs clinical skills through the mentoring program (TG 187), QIU RN
Supervisor, PCMO evaluations and other Peace Corps approved assessments.
These evaluations include appraisal of each RN PCMOs clinical skills in:
- History taking
- Physical exam and lab skills
- Using the eCHAM to make assessments
- Ability to follow and implement plans
- Implementing patient education
- Knowledge of and administering medications
- Performing certain treatment procedures
- Documenting the encounter
- Other quality improvement initiatives
C. The granting of standing orders should be individualized considering the following:
Not all RN PCMOs may receive all standing orders privileges.
Each RN PCMO comes to the job with different skills and abilities.
RN PCMOs master clinical skills at different rates, based on background, training,
clinical exposure and support.
Depending on individual knowledge, skills and abilities, a specific RN PCMO may be
granted:
- A full list of standing orders
- A limited selection of standing orders
RN PCMO will demonstrate competency at annual CME sessions directed to RN
PCMOs.
D. Documentation of standing orders
Condition-specific standing orders related to the eCHAM and TGs are documented
using TG 605 Attachments A and B, and are signed by the practitioner who has
verified competency and the D/OMS.
The signed standing orders document will be on file in the headquarters
credentialing file of the RN PCMO and the RN PCMOs clinic (Post).
Patient-specific Standing Orders for chronic medication and monitoring are
documented using TG 605 Attachment C or D, depending on the availability of a
prescribing provider at Post.
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When an RN PCMO treats a patient using standing orders without contacting the
prescribing provider, the RN will record this in the Volunteers medical record.
E. Renewing standing orders or change of supervising physician
Standing orders must have re-evaluation and renewal every two years to
emphasize the importance of maintaining knowledge and skills.
The RN PCMO functions only under the medical supervision of the prescribing
physician.
If standing orders are not renewed, the RN PCMO may no longer treat patients using
standing orders and must report each patient to the prescribing provider, as
directed in the eCHAM.
F. Revoking standing orders
The supervising physician (D/OMS) can revoke a standing order if that physician
determines that an RN PCMO does not have the skills or resources as outlined above
to treat patients for that specific problem without contacting the physician
Revocation of standing orders must be in writing after consultation with the RN
PCMO, RMO and the QI Unit
- Revoked Standing Orders may be reinstated after a period of successful
remediation
G. Change of RN PCMO employment
Standing orders are specific to a nurse and a physician.
If a RN PCMO changes employment to a different Peace Corps facility, or itinerates in
the agency, their original standing orders carry over with them.
Questions:
Questions regarding RN standing orders should be directed to the D/OMS or Quality
Improvement Unit RN Supervisor in the Office of Health Services.
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Peace Corps
ANAPHYLAXIS
1. PURPOSE
To provide guidance in the recognition and treatment of anaphylaxis and to define the
supplies and treatment protocol required to manage anaphylaxis.
2. BACKGROUND
Allergic reactions can occur to various drugs and other environmental allergens. They can
vary in severity from mild pruritus to life threatening anaphylaxis.
Types of allergic reactions
TIME
CLINICAL MANIFESTATIONS
Immediate ( < 1 hr )
Urticaria, hypotension, bronchospasm (asthma), laryngeal

edema
Accelerated ( 1-72 hrs )
Urticaria, morbilliform eruptions, laryngeal edema
Late ( 3-7 days )
Urticaria, skin rashes, drug fever, serum sickness like reactions
Very late ( > 1 week )
Hemolytic anemia, thrombocytopenia, granulocytopenia,

Stevens-Johnson syndrome, cholestatic jaundice
3. ANAPHYLAXIS
Anaphylaxis is the most severe and dangerous form of allergic reaction. The reaction may
occur within seconds or can take hours to develop. In some cases, symptoms of anaphylaxis
can return several hours after the initial episode.
The cause for anaphylaxis may remain unidentified in as many as two thirds of the case. The
following is a list of more common causes of anaphylaxis:
Antibiotics (penicillins, cephalosporins, sulfonamides, vancomycin)
Hypertonic solutions (contrast media, e.g. for IVP)
Insect bites and stings
Foreign proteins, preservatives and stabilizers (gamma globulin, immunizations)
Foods (esp: peanuts, seafood, eggs)
Airborne allergens (pollens, molds, danders)
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Anti-inflammatory drugs (aspirin, ibuprofen, etc.)
Latex
Exercise
4. PREVENTION OF ANAPHYLAXIS
Volunteers are screened to identify those at risk of severe allergic reactions.
Volunteers should be educated about the dangers of using a drug or eating a food to
which they may be allergic.
A medical history for allergies is taken prior to the administration of any drug.
Give drug orally rather than parenterally when possible
Volunteers should remain in the Health Unit for at least 20 minutes following
immunization or injected medication.
If there is any doubt as whether a particular medication can be used, contact the APCMO
or OMS.
Medical records must be updated to include newly identified drug allergies.
Skin testing, drug challenges and desensitization can cause anaphylaxis; they must not be
used in-country except under the direction of OMS.
5. TREATMENT OF ANAPHYLAXIS
As prompt appropriate therapy can be lifesaving, the anticipation of a possible anaphylactic
reaction is vital and preparations for emergency treatment must be made.
A protocol for the treatment of anaphylaxis and the necessary supplies must be available
wherever and whenever immunization and parenteral medications are given. If
immunizations are given in locations other than the Health Unit (such as training or
conference sites), the basic medications and equipment must be available at that site.
5.1
Supplies Necessary To Treat Anaphylaxis

Drugs and equipment for the treatment of anaphylaxis should be stored in an easily
accessible area in the Health Unit and inspected monthly. When administering
immunizations, these supplies should be placed adjacent to the PCMO in case of
immediate need.
Following is a list of the items necessary to treat most forms of anaphylaxis.
Drugs and Solutions:
DIPHENHYDRAMINE HCL (Benadryl) for IM/IV use

EPINEPHRINE (Adrenalin) 1:1000
ALBUTEROL (Proventil) and nebulizer or spacer
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IV SOLUTION (Four (4) 500ml containers of D5 Normal saline)

HYDROCORTISONE or METHYLPREDNISOLONE for IV use
Equipment:
5.2
BLOOD PRESSURE CUFF and STETHOSCOPE

SYRINGES and NEEDLES
PORTABLE OXYGEN with administration set
AMBU BAG and AIRWAYS
IV CANNULAS and TUBING (administration sets)
Endotracheal tubes, laryngoscopes, vasopressors and other critical care supplies
should be available if the PCMO is trained for these procedures and local access to
emergency medical care is inadequate.
Precautions Concerning Epinephrine

Epinephrine, given subcutaneously, intramuscularly, or intravenously, is the primary
drug used in the management of anaphylaxis. It affects the circulatory and respiratory
systems to rapidly counter the underlying pathophysiology of anaphylaxis.
Selecting the correct dose of epinephrine can be difficult. Too low a dose can result in
worsening of hypotension or airway obstruction, while too high a dose can precipitate
cardiovascular complications (see precautions-below.) The dose selected should be
appropriate for the severity of the patients symptoms (see ATTACHMENT A.)
If the response to a dose is incomplete, give the next dose sooner and add second-line
medications (inhaled bronchodilators, antihistamines, corticosteroids.) Remember that
corticosteroids will not take effect for 4-6 hours. Aggressive airway and fluid
management should be provided in addition to epinephrine for moderate to severe
anaphylaxis.
Use epinephrine with caution if:
Underlying cardiovascular disease
Age >35
Coexisting use of beta blockers
Some experts use glucagon 1mg SC, IM, or IV when epinephrine cannot be given or
when epinephrine does not produce a response (e.g., use of beta blockers.) Obtain
expert assistance in these situations.
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5.3
Intravenous or Intratracheal Epinephrine

Epinephrine may be given intravenously or via an endotracheal tube if severe
anaphylaxis does not respond to epinephrine administered subcutaneously or
intramuscularly (see ATTACHMENT A.)
Use either (1) or (2):
5.4
(1)
3-5 ml of epinephrine for IV administration (1:10,000 concentration), or
(2)
Prepare a dilution of 1ml standard epinephrine (1:1000) in 10 ml saline,

give 3-5 ml of the diluted dose IV or via endotracheal tube.
B-Agonist
Bronchospasm refractory to epinephrine may respond to a nebulized B-agonist such as
albuterol sulfate or metaproterenol. Continuous nebulization of the B-agonists may be
necessary for persistent bronchospasm. The use of anticholinergic therapy with
nebulized ipratropium bromide(Atrovent) is an additional option in the management of
bronchospasm.
5.5
Antihistamine
Antihistamines should be used in all cases, although their role in severe or persistent
anaphylaxis is limited. Diphenhydramine hydrochloride is the most commonly used H1
antihistamine. The typical dose 25 to 50 mg every 4 to 6 hours. For severe reactions, a
loading dose of 1 to 2 mg/kg IV to a maximum of 100 mg is recommended.
Blockade of H2 receptors may be beneficial with simultaneous H1 antihistamine
therapy. Cimetidine 300 mg IV, followed by oral administration of cimetidine 300 mg
every 6 hours for 2 days, should be considered for patients with persistent symptoms.
5.6
Corticosteroids
Corticosteroids have an onset of action of approximately 4 to 6 hours after
administration and therefore are of limited benefit in the initial treatment of the rapidly
deteriorating anaphylactic patient. Their benefit may be realized in persistent
bronchospasm or hypotension. An initial intravenous loading dose of hydrocortisone
(Solu-Cortef) 250 mg to 1 gm, or methylprednisolone (Solu-Medrol) 125 to 250 mg,
followed by oral prednisone over 7 to 10 days, is an acceptable regimen after the
anaphylactic episode.
5.7
Vasopressors (Dopamine, etc.)

Use of dopamine or other vasoactive drugs in an uncontrolled environment is risky but
may be necessary in extreme situations. They should only be used in the presence of
impending cardiovascular collapse or airway obstruction, after fluid resuscitation and
other measures have failed (see ATTACHMENT A.)
A quick reference chart for calculating the dopamine flow rates is included below. This
chart is included as an aid to the use of dopamine by PCMOs familiar with the use of
vasopressors. Always seek expert assistance.
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Dopamine Rapid Reference Chart

Prepare 400 mg dopamine in 500 ml D5W or other intravenous fluid.
Recommended dose for hypotension: 4 to 10 mcg/kg/min (see ATTACHMENT A)
If patient weighs:
Start infusion at
Increase slowly, up to
a maximum of
45 kg
100 lb
14 ml/hr
34 ml/hr
55 kg
120 lb
16 "
41 "
65 kg
142 lb
20 "
49 "
75 kg
165 lb
22 "
56 "
85 kg
187 lb
25 "
64 "
95 kg
210 lb
28 "
72 "
6. MEDICAL CLEARANCE IMPLICATIONS

Applicants (or Volunteers) with a history of anaphylaxis or other serious allergic reaction
may be at high risk abroad as there is a greater chance of exposures to potent allergens (e.g.
administration of horse serum by local health providers, stinging insects). There may also be
a lack of trained emergency medical personnel.
OMS must be notified if a Volunteer has a serious allergic reaction or anaphylaxis as the
Volunteers medical clearance will be reviewed.
CLINICAL PRESENTATION AND TREATMENT OF ANAPHYLAXIS
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Subjective & Objective
The clinical manifestations of anaphylaxis are best considered according to the organ system
that is effected (this allows therapy to be planned and understood):
Cardiovascular (tachycardia, hypotension, shock)
Respiratory (laryngeal edema, stridor, tachypnea, dyspnea, wheezing, cough)
Skin (pruritus (itching), cutaneous flushing, angioedema)
Gastrointestinal (nausea, vomiting, diarrhea, abdominal pain)
Eye and nose (tearing, sneezing, rhinorrhea)
Neurologic (anxiety, weakness, syncope)
Assessment
Differential diagnosis
Vasovagal collapse
Primary medical disorder (seizure, MI, hypoglycemia, dehydration, sepsis)
Panic attack
Airway obstruction
Plan
As the progression of anaphylaxis is unpredictable, appropriate treatment should begin

at the first sign of anaphylaxis.
Follow treatment algorithm - ATTACHMENT A
Moving the patient:

Consideration should be given to moving the patient to a better equipped facility as
soon as possible. First line emergency measures (epinephrine, Benadryl, vital signs)
should always be administered prior to moving the patient and remain available
during transport.
Observation after the acute phase:

All patients who have experienced an anaphylactic reaction should be closely
observed for 24 - 48 hours as the symptoms may recur. Therapy should be
reinstituted at the first sign of a recurrence. Use antihistamines and oral steroids as
indicated on the treatment algorithm.
Use of IV epinephrine, dopamine, or other vasoactive drugs:

Use of these drugs in an uncontrolled environment is risky but may be necessary in
extreme situations. They should only be used in the presence of impending
cardiovascular collapse or airway obstruction, after fluid resuscitation and other
measures have failed.
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MANAGEMENT OF ANAPHYLAXIS
TG 615 ATTACHMENT A
MODERATE ANAPHYLAXIS
MILD ANAPHYLAXIS
SEVERE ANAPHYLAXIS
(angioedema, severe bronchospasm,

hypotension (BP>80)
(urticaria, mild bronchospasm)
Assess airway
Epinephrine without delay
(airway obstruction-laryngeal edema

or larynospasm, severe hypotension)
Maintain or establish airway

Assess airway
Oxygen 10L face mask if available

Vital signs q 15 min
Summon medical assistance

Keep patient supine, elevate
legs if hypotensive
100% oxygen
Continuous monitoring
Summon medical assistance

Keep patient supine, elevate legs
if hypotensive
Oxygen 10L face mask if available
Vital signs q 5-10 min
Epinephrine* (1:1000) 0.3-0.5 ml SQ,

repeat every 10-15 minutes x 3
Epinephrine* (1:1000) 0.5 ml SQ,

repeat every 5-10 minutes x 3
Benadryl 50 mg IM
Benadryl 50 mg IM
Epinephrine* (1:1000) 0.5 ml IM

repeat every 1-5 minutes, proceed
to IV or endotracheal epinephrine if
no reponse
Hypotension or upper
airway obstruction
continues
Symptoms resolve
Bronchospasm
continues
Bronchospasm
continues
Epinephrine* (1:10,000)** 3-5 ml

via slow IV push over 5-10 minutes, or
via endotracheal tube;
repeat if necessary
Monitor closely for 24-48 hrs

Oral Benadryl 25-50mg qid
Consider glucagon if patient is using

beta blockers
Albuterol (Proventil) 2 puffs via

spacer or nebulizer. Continue as
often as necessary to achieve a
response
Atrovent
Multiple 16 gauge IV lines

IV Normal saline 1 liter every 20-30
min up to 2-3 liters
0.5 mg (2.5 ml of a
0.02% solution) via
nebulizer
Methylprednisolone
125 mg IV, or
Hydrocortisone 500 mg IV, or
Prednisone 60 mg PO
Symptoms resolve
Monitor closely for 24-48 hours

Continue oral corticosteroids and
Benadryl 25-50 mg qid
Contact APCMO/OMS
Methylprednisolone
250 mg IV, or
Hydrocortisone 1 gm IV
Persistent upper
airway obstruction
Intubation,
cricothyroidotomy, or
tracheostomy
Persistent hypotension
Dopamine
4-10 mcg/kg/min
(see text)
* See epinephrine precautions

** Dilute 1ml of 1:1000 in 10ml saline to produce 1:10,000
if necessary (see section 5.3)
Glucagon 1mg SC, IM, or 1-5mg IV may be used when
epinephrine cannot be given or when it does not produce
a response (e.g., use of beta blockers.)
Peace Corps
FEVER - GENERAL CONSIDERATIONS AND INVESTIGATION

1. PURPOSE
To provide guidance in the assessment of a febrile patient.
2. BACKGROUND
Normal body temperature
Body temperature follows a circadian rhythm with about 0.6oC (1oF) of daily variation
from a low point in the early morning to a peak between 4-6 pm. Normal body
temperatures also vary from person to person. Ideally, fever is defined as an increase in
temperature from normal for that person, however it is rare in practice to have recorded
baseline temperatures at various times of the day for comparison.
Typical normal temperatures are:
Oral:
97o to 99.9o F (36.1o to 37.7o C)
Rectal:
97.5o to 100.9o F (36.4o to 38.3o C)
What causes a fever?
The thermoregulatory system (located in the hypothalamus of the brain) usually

maintains the bodys temperature between 97o and 99.9o F (36.1o to 37.7o C.) See
Technical Guideline 880 Heat Related Illness for a description of thermoregulation.
Fever occurs when the regulatory system maintains the bodys temperature at higher than
normal levels. Fever often accompanies infection. The infecting bacteria or viruses
release toxins (exogenous pyrogens) which cause certain immune cells to release
chemicals (endogenous pyrogens) which cause the hypothalamus to raise the bodys
temperature.
The thermoregulatory system tries to keep the bodys temperature at the higher pyrogeninduced temperature by inducing shivering if the temperature is below this new set-point,
or sweating if the temperature is above it. This produces the alternating sweating and
shivering (rigors) seen in febrile patients.
In young, otherwise healthy adults, infection causes most fever. Other causes of fever
(certain cancers, drug fever, auto-immune diseases) are rare.
Fever in itself is usually dangerous only if 106o F (41o C); however, fever almost
always causes uncomfortable symptoms. In young children, fever can be associated with
febrile convulsions.
General considerations in the assessment and treatment of the febrile patient
Most common infections (and their associated fevers) resolve spontaneously. This is true
for most colds, flu, bronchitis, etc. In these cases, cautious observation and symptomatic
treatment are all that is required.
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Fever
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If the history and/or examination indicate that this may be a serious infection, if a
probable source of the fever is identified (e.g., UTI), or if the patient has been exposed to
any potentially serious infectious diseases, investigations and treatment are appropriate.
Use of anti-pyretics
In adults, the use of anti-pyretics (e.g., aspirin, acetaminophen, or NSAIDs) to reduce

fever is somewhat controversial; however, they are commonly used to make the patient
feel more comfortable. Nevertheless, it is much more important to find and treat the
cause of the fever whenever possible.
To aid in the management of a patient with a fever, the PCMO should be able to
answer the following questions:
Could this be a serious infection?
Are there any symptoms or examination findings that indicate which body system is
involved?
What tests should be performed to arrive at a definitive diagnosis?
What are the common pathogens associated with these symptoms or system? What is
the optimal therapy to treat these pathogens? Is any treatment (including empirical
treatment) required at this time?
Are there any public health implications of this illness?
3. IDENTIFYING A SERIOUS FEBRILE ILLNESS

The following table helps to identify more serious febrile conditions.
SERIOUS FEBRILE ILLNESS
A febrile adult may have a serious illness if:

SUBJECTIVE
The illness occurs in an area in which serious infectious diseases are known to occur (e.g.,
malaria, typhoid, meningitis.)
The fever persists more than 3 - 4 days.
There are symptoms present which may be associated with a serious illness (e.g., vomiting,
diarrhea, headache, neck pain, alterations in mental status, urinary symptoms, severe
cough, shortness of breath, bloody diarrhea, etc.)
OBJECTIVE
Any of: Fever 38.5o C (101o F)
Very fast pulse (> 100 /min)
Raised respiratory rate (> 24/min)
Abnormal blood pressure (low or high)
The patient looks unwell, is debilitated and/or confined to bed.
The examination is abnormal (e.g., low BP, abdominal tenderness, rash, neck stiffness,
altered mental status, etc.)
Important screening laboratory tests are abnormal (e.g., pyuria, WBC > 15,000, abnormal
X-ray.)
March 2006
Page 2
Fever
TG 620
SERIOUS FEBRILE ILLNESS (CONT.)
ASSESSMENT
The urgency with which a febrile patient is investigated and/or treated depends on:
Whether the diagnosis is known and is one which requires treatment
Whether this may be a serious infection
AND
The condition of the patient
PLAN
Diagnosis known: treat accordingly
Diagnosis not yet made: supportive care, appropriate tests, and frequent review
A patient who is very unwell, or who may have a serious illness, may be investigated (if
possible) and then given empiric antibiotics to cover the most likely infections (even before
the exact diagnosis is known.) Obtain expert consultation.
4. INVESTIGATING A SERIOUS INFECTION

In cases in which the patient may have a serious infection, it is vital that a thorough history
and examination be performed. This may suggest a possible location of the infection.
Obtain expert advice from OMS, the APCMO, or an in-country consultant.
The investigations required depend on the most likely location of the infection.
Initial investigations (all patients):

CBC with differential
Blood cultures (X 3)
Urine microscopy and culture
Malarial smears (if risk of exposure - see TG 845)
Central nervous system (headache, neck stiffness, altered mental status, etc.):
Lumbar puncture (if meningitis suspected)
Respiratory system (cough, sputum production, raised respiratory rate, crackles and/or
wheezes, reduced air entry, etc.):
Sputum microscopy and culture
Chest X-Ray
TB skin test and possibly sputum for TB culture and acid fast smear if cough persists
for > 2 weeks (see TG 645 Pulmonary Tuberculosis)
Urinary tract (dysuria, frequency, urgency, hematuria, abdominal or flank pain.):

Repeat urine microscopy and culture
For possible acute schistosomiasis (Katayama fever, see TG 850):

Repeated urine and stool microscopy
CBC with differential (eosinophilia)
Schistosomiasis antibody testing (often negative in acute infection)
March 2006
Page 3
Fever
TG 620
5. CAUSES OF FEVER ASSOCIATED WITH A RASH

Fever with rash is most commonly caused by an infectious disease.
Many infectious diseases first present with a common set of symptoms (often called a
prodrome) which may include: fever, malaise, nausea, vomiting, myalgia (muscle pains),
arthralgia (joint pains), headache, and photophobia (eyes sensitive to bright light.)
More specific symptoms may also develop; these can make a particular diagnosis more
likely. Examples of such symptoms include: neck-stiffness, diarrhea, abdominal pain, or
rash.
The presence, type, and distribution of a rash provide vital clues in the diagnosis of a
febrile patient.
5.1
Definitions
Description of a rash
It is important to be able to describe rashes accurately. The following terms are
commonly used to describe them:
Macule:
Discolored spot on the skin; neither raised nor depressed
Papule:
Elevated, firm, circumscribed area on the skin. May or may not be

discolored or pigmented (e.g., warts)
Vesicle:
Fluid filled papule (e.g., herpes, shingles, cold sores)
Pustule:
Vesicle filled with purulent liquid (e.g., boil)
Petechia:
Non-blanching pinpoint hemorrhage into the skin. Usually

multiple. Usually indicates defect in blood clotting mechanism.
Purpura:
Larger areas of bleeding into the skin. Also known as bruises.
Types Of Rash
Two main types of rashes are associated with infectious diseases:
5.3
Maculopapular:
A rash with macules and papules. It blanches on pressure (this can

be demonstrated using a glass slide.)
Hemorrhagic:
A rash caused by bleeding into the skin. It does not blanch on

pressure. There are two types of hemorrhagic rash: petechial and
purpuric.
Differential Diagnosis of the Febrile Patient with a Rash.

There are many causes of fever and rash. ATTACHMENT A is a flow diagram which
helps to distinguish the various causes of fever associated with a rash. It concentrates
on the type and distribution of the rash.
March 2006
Page 4
Fever
TG 620
Hemorrhagic rashes are the most severe types of illness presenting with fever and rash.
Meningococcal septicemia is one of the few conditions in this group which is both lifethreatening and treatable with antibiotics. If meningococcal septicemia is suspected
treat as for bacterial sepsis (see section 6.)
Additional information which is helpful when evaluating febrile patients with a rash:
Review all medications and immunizations over in the past 30 days.
Review drug allergies.
Consider infectious disease exposures at their site and any in-country or

international travel in the past 6 months or more. Any contact with febrile or ill
people in the last few weeks?
Exposure to wild animals or poor hygienic conditions possibly contaminated by

wild animals?
Consider occupational exposures.
Ask about sun exposure, any history of sun-induced skin conditions.
Exposure to STDs (syphilis, acute HIV.)
Heart murmur or history of valvular heart disease.
Any pets? Any significant hobbies or habits?
6. EMPIRIC TREATMENT OF SEVERE BACTERIAL INFECTIONS
Severe bacterial infections, including blood stream infections, deep abscesses, and CNS
infections, can rapidly overwhelm the bodys defenses, often leading to multi-organ
system failure (septic shock.)
Catastrophic illness or shock may also be due to non-bacterial conditions, such as cardiac
events or surgical emergencies. Empiric antibiotics are appropriate in addition to other
diagnostic and supportive measures when a severe bacterial infection is suspected.
A combination of antibiotics should be used to cover the types of bacteria suspected.

Localizing signs as to the origin or site of infection are important in selection the
appropriate antibiotics for empiric use.
Blood cultures should be done along with cultures of all potential sites (urine, sputum,
wounds, etc.) Empiric antibiotic treatment can be changed if cultures or other tests
confirm the organism or rule out bacterial infection.
Patients with severe sepsis should receive a broad-spectrum, intravenous regimen that is
effective for both gram-negative and gram-positive bacteria. The choice of drugs should
be modified according to the patients own microbiologic culture data and the resistance
patterns prevalent in the patients community or hospital.
Contact the APCMO or OMS when managing a Volunteer with a severe and possibly
life-threatening illness such as sepsis or shock.
March 2006
Page 5
Fever
TG 620
Empiric Treatment of Severe Bacterial Infections

Ceftriaxone 1 gram IM or IV every 12 hrs* AND
ADD ciprofloxacin (750mg PO every 12 hrs) if stable without signs of shock*
OR gentamycin 2 mg/kg IM or IV as a single loading dose if signs of shock are present*,
ADD metronidazole 500mg PO or IV every 6 hours if abdominal infection is suspected*
* Ceftriaxone is adequate for initial coverage of suspected meningitis. Add ciprofloxacin if severe
infection is suspected but the patient is stable without signs of shock. Add gentamycin or
equivalent (tobramycin (2 mg/kg IM or IV) or amikacin (10 mg/kg IM or IV)
A loading dose of gentamycin or tobramycin is adequate for 8 hrs, a loading dose of amikacin is
adequate for 12 hrs. Consult with APCMO or OMS to discuss continuing or changing antibiotic
coverage.
March 2006
Page 6
Peace Corps
Common Skin Infections
1.
PURPOSE
This guideline provides a summary of the management of bacterial, parasitic, and fungal skin
infections.
The recommendations provided in this guideline are designed to address the empiric treatment of
syndromes commonly seen by the PCMO. The treatments listed concentrate on the antibiotics or
medications which are most useful to stock in the health unit. Occasionally, due to drug allergy or
intolerance, alternate drugs may be necessary. Consult the UpToDate for additional or more
detailed information.
2.
BACTERIAL SKIN INFECTIONS

Bacteria (Strep & Staph aureus) cause most skin infections and systemic antibiotics may be
required to treat these infections. Antibiotics do not replace the basic measures of wound cleansing,
drainage of pus and debridement of dead tissue.
Topical antiseptics/antibiotic ointments such as chlorhexidine gluconate (Hibiclens),
bacitracin/triple antibiotic ointment, and mupirocin (Bactroban) are useful for the treatment of
superficial infections. Of these, only mupirocin has been shown to be as effective as systemic
antibiotics for the treatment of impetigo. Creams and ointments containing neomycin are not
recommended due to the frequency of topical allergy to neomycin. (Note: neomycin-free antibiotic
ointments and creams are readily available. When purchasing replacement antibiotic ointments
exclude those with neomycin.)
Duration of antibiotic treatment
Duration of treatment is often listed as a range, such as 5-10 days, rather than a fixed number of
days. More severe infections should be treated for the maximum number of days listed and
treatment may be continued beyond this point or another treatment chosen if a complete response is
not seen. Mild infections which promptly respond to treatment can be treated for the shorter
duration given.
2.1
Impetigo
Impetigo is a superficial, contagious skin infection caused by Staph aureus and/or Group A
Strep. It often begins with a vesicle which later ruptures to form a thick, yellow crust.
Antibiotic treatment is warranted due to a high recurrence rate. Unlike strep pharyngitis,
treatment does not appear to prevent the development of post-streptococcal
glomerulonephritis. Good handwashing should be encouraged.
March 2016
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Skin Infections
TG 635
Treatment of impetigo
Clean site, apply mupirocin (Bactroban) three times a day for 5 days (discontinue and
reevaluate if lesions worsen)
Or, for more severe infections:
Dicloxacillin 250-500mg orally four times daily for 7 days
Or
Cephalexin 250-500mg orally four times a day for 7 days
Or, for penicillin/cephalexin allergic
Erythromycin 250mg orally four times daily for 7 days
If MSRA is suspected/confirmed
Clindamycin 300-450 mg orally four times daily for 7 days
Or
Trimethoprim-sulfamethoxazole 1-2 doubles strength tablets orally twice daily for 7 days
Or
Doxycycline 100mg orally twice daily for 7 days
2.2
Skin abscess
Skin abscess (boils, furuncles, carbuncles) are a localized skin infection, often starting in hair
follicles, and containing a collection of purulent material. A carbuncle involves multiple hair
follicles and may be associated with fever and malaise. The majority are caused by Staph
aureus.
Treatment
Warm compresses promote drainage and are usually sufficient for small boils. Large
abscesses require incision and drainage; antibiotics are not required unless there are multiple
lesions or systemic symptoms.
If antibiotics required, use:
Dicloxacillin 500mg orally four times daily for 5-10 days
or
Cephalexin 500mg orally four times a day (or 500mg twice a day) for 5-10 days
If MSRA is suspected use:
Clindamycin 300 to 450mg orally three to four times daily for 5-10 days
or
Trimethoprim-sulfamethoxazole 1 to 2 DS tablets orally twice daily for 5-10 days
or
Doxycycline 100mg orally twice daily for 5-10 days
For repeated episodes, consider intranasal (and possibly under the fingernails) mupirocin
(Bactoban) twice a day for 5 days to eliminate Staph Aureus colonization.
March 2016
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Skin Infections
TG 635
2.3
Cellulitis
Cellulitis is non-localized infection of the skin and connective tissue. It is usually caused by
Beta-Hemolytic Strep (Groups A, B, C, G and F) or Staph aureus (including methicillinresistant strains). Cellulitis presents as a warm, erythematous, tender areas of skin, often
associated with regional lymphadenopathy. The lower extremities are the most common site.
Signs of systemic toxicity such as fever, malaise and nausea may be present. Cellulitis must be
closely monitored (observed daily by the PCMO) until a clear response to treatment is seen.
IV therapy is appropriate when fever or systemic symptoms are present.
Purulent cellulitis (associated with purulent drainage or exudate, in the absence of a
drainable abscess) should be managed with empiric therapy for infection with MRSA.
Treatment of purulent cellulitis
______________________________________________________________________________________________
_________
Elevation of the affected area facilitates gravity drainage of edema and inflammatory
substances.
Clindamycin 300 to 450 mg orally three to four times daily for 5-7 days
Trimethoprim-sulfamethoxazole one to two DS tablets orally twice a day for 5-7 days
Doxycycline 100 mg orally twice daily for 5-7 days
(Treatment may be extended for up to 14 days. More severe infections require IV
therapy)
______________________________________________________________________________________________
Non-purulent cellulitis (no purulent drainage or exudate and no associated abscess)

Treatment of non-purulent cellulitis
Elevation of the affected area facilitates gravity drainage of edema and inflammatory
substances.
For beta-hemolytic strep or MSSR
Dicloxacillin 500mg orally four times daily for 5 7 days
or
Cephalexin (Keflex) 500mg orally four times daily for 5 7 days
or
Clindamycin 300 to 450 mg orally three to four times daily for 5 7 days
For suspected MSRA
Clindamycin 300 to 450 mg orally three to four times daily for 5 7 days
Amoxicillin 500 mg orally three times daily with Trimethoprim-Sulfamethoxazole one to
two double-strength tablets orally twice daily for 5 7 days
March 2016
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Skin Infections
TG 635
Amoxicillin 500 my orally three times daily with Doxycycline 100 mg orally twice daily for
5 7 days
(Treatment may be extended for up to 14 days. More severe infections require IV
therapy)
2.4
Bites
Clean all bite wounds promptly and thoroughly with soap and water.
Human bites commonly become infected with staph aureus, strep or oral anaerobes. Cat
and dog bites may also transmit Pasturella multocida. Prophylactic antibiotics should be
given within 12 hours of a bite to prevent infection.
Check immunization records to confirm that the Volunteer had a tetanus booster within
the past 5 years.
X-ray the finger, hand, etc. if a deformity is present to rule out a fracture (increased risk of
osteomyelitis.) Contact RMO or OHS if a fracture is seen.
Anti-rabies treatment may be indicated for dog, cat, bat, and many terrestrial mammal
bites which occur in rabies-endemic areas. Refer to Technical Guideline 300
Immunization. Rodent bites (e.g., squirrels, rats, mice, rabbits or hares) do not normally
require anti-rabies treatment.
SPECIAL NOTE: Bites from several species of Asian monkeys may transmit Herpes B
virus (formerly referred to as Herpesvirus simiae) which produces a progressive,
sometimes fatal infection in humans ultimately involving the nervous system.
Monkeys who are the natural hosts of the Herpes B virus are all members of the Macaca
genus, which includes rhesus monkeys and pigtail macaques. Captive monkey
populations have a 30-100% rate of infection. Herpes B virus produces a mild disease in
these species, which is similar to herpes simplex in humans.
African or New World monkeys may become infected if they are in close contact with
infected monkeys; however, this is unlikely in wild or domestic monkeys outside of Asia.
In addition, monkeys other than those of the Macaca genus rapidly become ill after
infection and so rarely transmit the virus.
Cleaning the wound within 5 minutes for at least 15 minutes decreases the likelihood of
herpes B virus. Consult OHS for monkey bites occurring in Asia or from monkeys which
are in close proximity to Asian monkeys (zoos, laboratories). Prophylaxis treatment with
acyclovir or valacylovir should be considered. In addition, provide antibiotic treatment for
all monkey bites as described below.
March 2016
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Skin Infections
TG 635
Prophylaxis and treatment of infected bites

Preferred Treatment for all Types of Bites (see above concerning monkey bites)
Amoxicillin- Clavulanate (Augmentin) 875/125mg twice daily for 5 days
See UpToDate for alternative regimes
3. SCABIES
Scabies is a common skin infestation caused by Sarcoptes scabei, a virtually invisible mite which is
transferred by close or skin-to-skin contact, often, but not necessarily sexual contact.
Scabies is characterized by dozens to hundreds of tiny, punctate excoriations, and nodules and a
few superficial burrows. Interdigital areas, the penis and scrotum, umbilical and pubic regions,
ankles, and breasts are the classic sites of involvement. Inflammatory nodules on both the penis and
scrotum may occur in males and on the areola in females.
Mites survive for only 2-3 days when separated from the host. Close physical contact is the primary
mode of transmission. Contaminated clothing or bedding may also cause infections.
The diagnosis of scabies is based on the clinical presentation and can be confirmed by scraping
burrows (short elongated wavy papules often found on the webs of the fingers) with a No. 15 blade
and applying the scrapings to a glass slide along with drops of oil or water. When the preparation is
examined under a low-power microscope, intact mites, eggs, or waste material may be seen.
Clothes and bedding should be washed in hot water and close (intimate) contacts treated to prevent
reinfection.
Treatment of scabies
Permethrin 5% cream
After an evening shower or bath, apply the cream to the entire body from the neck down
(including perineum.) Wash the cream off the next day (8-14 hours later.) One 60 gm tube
should treat 1-2 persons. Treat close physical contacts. A second treatment 1-2 weeks later
may be considered.
Itching may continue for one to two weeks following successful treatment due to the hypersensitivity
reaction to mites, feces and eggs. Antihistamines can help control the itching. Symptoms should
progressively improve. If symptoms worsen despite adequate treatment, consider re-exposure.
4. PEDICULOSIS (LICE)
Lice infest three main areas of the body; the scalp, the pubic region, and the trunk. Infestations of
these areas have the following differentiating characteristics:
March 2016
Page 5
Skin Infections
TG 635
The scalp (Pediculosis capitis/head lice):
Head lice cause itching of the scalp or eyebrows.
Examination reveals adult lice in the hair with nits attached to hair shafts.
Head lice can easily be spread by casual head to head contact and by objects such as shared
combs or hats.
The pubic region (Pediculosis pubis/pubic lice):
Pubic lice infest the pubic region and sometimes the axilla or eyelashes.
Pubic lice cause itching in the effected area.
The lice can be seen with close examination.
Infection is spread through intimate, usually sexual, contact.
The body (Pediculosis corporis/body lice):
Commonly associated with poor hygiene and causes diffuse erythematous macules, wheals, and
excoriations, often with secondary bacterial infection (e.g., impetigo, cellulitis.)
The lice usually reside on clothing and only come onto the skin to feed.
Trench fever, relapsing fever, and typhus are transmitted by the body louse in endemic areas.
Treatment of Pediculosis
Medication
Permethrin 1% cream/liquid
Apply to the effected areas for 10 minutes and then wash off. Retreatment in 7 10 days
may be necessary.
or
Lindane shampoo/lotion 1% (is no longer recommended as first line treatment due to
neurologic toxicity. Use only for treatment failures or inability to tolerate other
therapies.)
Apply to affected areas, wash off after 4 minutes. Do not retreat.
Remove nits with a fine-toothed comb
Environmental
Capitis All hats, brushes, towels, linens or other items in contact with the infected person
should be washed in hot water or placed in a plastic bag for two weeks to prevent reinfestation.
Corporis All infested clothes, bedding and towels should be washed in hot water or placed in
a plastic bag for two weeks. With continued good hygiene, medication may not be necessary.
March 2016
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Skin Infections
TG 635
Pubis All clothes, bedding and towels should be washed in hot water or placed in a plastic
bag for two weeks. Recent sexual partners should also be treated.
5. FUNGAL SKIN INFECTIONS

Fungal skin infections are relatively common among Volunteers, especially in tropical climates.
Three types of dermatophytes what account for the majority of infections Trichophyton,
Epidermophyton, and Microsporum. These fungi infect the scalp, the body, the groin, and the
hands and feet. It is not important to know which species cause infection in a particular area.
Another type of fungus, causing Pityriasis versicolor, in which patches of the skin have altered
pigmentation, is discussed in section 6.
The presence and level of host immunity to fungi determines the course and severity of any infection.
Body (Tinea corporis, Ringworm)
Produces scaling, erythematous rash with raised borders and central clearing.
Differential diagnosis includes: Eczema, psoriasis, pityriasis rosea.
Perineum and upper, inner thighs (Tinea cruris, Jock itch)
Produces an erythematous, pruritic rash with raised borders on perineum and upper, inner
thighs; scrotum is usually spared.
Differential diagnosis includes: psoriasis, seborrheic dermatitis, candida, irritant or allergic

dermatitis.
Feet (Tinea pedis, Athletes foot)
Produces pruritic, scaly soles, painful fissures between the toes, and occasionally vesicular
dermatitis of the instep of the sole.
Differential diagnosis includes: allergic contact dermatitis, cutaneous candidiasis, eczema,

psoriasis
Scalp (Tinea capitus, Ringworm)
Primarily a disorder of children. Produces irregular or round eczematous areas on the scalp
which may have hair loss or broken hairs. Must be treated with systemic antifungalscontact OMS if suspected in a Volunteer.
Differential diagnosis includes: psoriasis, seborrheic dermatitis, alopecia impetigo.
5.1
Diagnosis of tinea
Diagnosis can often be made clinically.
March 2016
Page 7
Skin Infections
TG 635
For confirmation or in uncertain cases, obtain skin scrapings by scraping the edge of the rash
with a scalpel blade.
5.2
Dissolve scrapings or hair in 10% potassium hydroxide solution (KOH test) and examine
under a microscope for hyphae or spores.
Culture (Sabourauds medium)
Treatment of fungal skin infections

General measures
The skin should be kept dry. Dry the skin carefully after bathing or perspiring heavily; wait 15
minutes before dressing or use a hair dryer on low setting (if possible). Underwear should be
loose fitting. Socks and other clothing should be changed frequently. Sandals or open-toed
shoes should be worn if possible. Skin secretions can be controlled with talc or other drying
agents.
Topical anti-fungal agents (except scalp and nail infections)
Clotrimazole 1% liquid, cream, or lotion
or
Miconazole 2% cream
or
Tolnaftate 1% solution or cream
Apply to rash three times a day; continue for 1 - 2 weeks AFTER the rash has cleared.
The addition of a topical steroid cream (e.g., Betamethasone 0.05%) for the first few
days may be beneficial for acutely inflamed lesions.
______________________________________________________________________
6. PITYRIASIS VERSICOLOR (Tinea versicolor)

Introduction
Pityriasis (tinea) versicolor is a very common superficial fungal infection of the skin caused by
saprophilic, lipid dependent yeasts of the genus Malassezia, which are a component of normal skin
flora. It is characterized by hypopigmented, hyperpigmented or erythematous macules, most often
on the trunk or upper extremities.
Tinea versicolor occurs worldwide, but the highest incidence is in tropical climates, with a
prevalence is as high as 50 percent. It is not contagious.
Clinical presentation
The rash usually affects the trunk, neck, proximal extremities. The face, scalp and genitalia are less
commonly involved. It consists of small hypo or hyper pigmented patches that coalesce as they
enlarge.
March 2016
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Skin Infections
TG 635
Although tinea versicolor can be mildly itchy, it mainly presents a cosmetic problem.
Diagnosis
The presentation is distinctive and the diagnosis is often made clinically. A KOH preparation of the
scales shows both hyphae and budding yeast. See section 5.1. Woods lamp will only be positive in
approximately one third of the cases
Treatment of pityriasis versicolor
Selenium sulfide 2.5% (Selsun) lotion or shampoo
Apply undiluted to affected skin for ten minutes then wash off. Repeat for 7 - 14 consecutive days.
Monthly application may prevent recurrence.
Inform the Volunteer that it will take 2 - 3 months before the lesions regain the same color as the
surrounding skin.
REFERENCES
UpToDate:
Impetigo, February 26, 2015

Skin abscesses, furuncles, and carbuncles, March 20, 2015
Cellulitis and erysipelas, October 12, 2015
Initial management of animal and human bites, August 19, 2015
Scabies, May 21, 2015
Pediculosis capitis, November 21, 2015
Pediculosis corporis, November 25, 2015
Pediculosis pubis and pediculosis ciliaris, February 2, 2014
Dermatophyte (tinea) infections, November 23, 2015
Tinea versicolor (Pityriasis versicolor), March 17, 2015
Medscape Reference, http://emedicine.medscape.com/:

Dermatology
Bacterial Infections
Cutaneous Abscess Empiric Therapy, Aug 15, 2014
Cutaneous Abscess Organism-Specific Therapy, Aug 15, 2014
March 2016
Page 9
Peace Corps
PULMONARY TUBERCULOSIS
1. PURPOSE
To provide basic information concerning tuberculosis screening, preventative therapy for
dormant infections, and the diagnosis and treatment of active pulmonary tuberculosis as they
relate to Volunteers serving overseas.
2. BACKGROUND
Tuberculosis is an infection caused by the acid fast bacillus Mycobacterium tuberculosis.
The term tuberculosis infection is often used to refer to inactive infection, and the term
tuberculosis disease to refer to active pulmonary or extrapulmonary TB (see below.)
Distribution
Tuberculosis is present worldwide. All Volunteers are considered to be at risk of exposure,
particularly as tuberculosis is endemic in many Peace Corps countries.
In most developing countries it is estimated that the rate of new TB infections ranges from
1%-2.5% per year. This rate refers to the risk of an uninfected person becoming infected
the majority of infections are asymptomatic as described below. Overall, about one third of
the population of the world is infected with tuberculosis.
The immunosupression associated with HIV infection has led to a worldwide increase in
tuberculosis. TB is a leading cause of death in adults throughout the world, and is the most
common cause of death due to an infectious agent worldwide.
Pathophysiology
There are two categories of infection, inactive (dormant or latent TB) and active TB.
Inactive tuberculosis
Initial TB infection involves the pulmonary macrophages, regional lymph nodes, and
hematogenous spread to many organs including the apices of the lungs. After 2 to 10
weeks, the hosts immune response halts infection and inactive (latent) infection
results.
A positive tuberculin skin test is often the only indication of TB infection at this
stage. Persons with reduced immunity may not show a positive reaction despite
infection. Active TB is one cause of a decreased immune response to tuberculin skin
testing (see below.)
Persons with inactive TB are not contagious.
May 2005
Page 1
Pulmonary Tuberculosis
TG 645
Most persons will not show x-ray evidence of initial infection of the alveoli and
regional lymph nodes or of hematogenous spread to the lung apices or other organs.
Calcified granuloma may be seen on the chest x-ray in inactive TB. Viable bacilli are
often present in these foci.
In most cases, the mycobacteria are controlled by the bodys defenses and the patient
does not develop symptoms. TB infection may remain inactive for the life of the
patient or may reactivate when the patients immunity is reduced (e.g., old age, HIV
infection, malnutrition, use of steroid drugs).
About 10% of infected persons eventually develop clinically active tuberculosis at

some time if they do not receive preventive therapy (5% within the first 2 years and
5% later in life.) This risk increases to as high as 80% in immunosupressed persons
(especially in persons with HIV infection.) In about 15% of active cases, usually
years after the initial infection, tuberculosis may present as an infection outside the
lungs.
Isoniazid (INH) treatment of recently infected persons without clinically active

disease is highly effective in reducing their chance of developing active disease (7090% reduction depending on compliance and duration of treatment.)
Active tuberculosis (see section 6)
Occasionally, TB infection is not controlled by the hosts immune response and

pulmonary or extrapulmonary disease is seen at either the site of initial infection
(lower lungs) or the sites of hematogenous spread (upper lungs or other organs.) In
children, massive spread throughout the body may occur (miliary tuberculosis.)
More often, TB infection remains dormant for months or years, and reactivates in
about 10% of those infected. The risk of reactivation is highest in the first two years.
In adults, about 85% of TB disease occurs in the upper parts of the lungs and about
15% is extrapulmonary. After reactivation of pulmonary TB, infection may spread to
the bronchi, larynx, and other regions of the lungs as drainage develops from infected
areas.
Extrapulmonary tuberculosis (outside the lungs) is usually due to reactivation of

latent infection. It may involve any part of the body and can mimic other diseases,
including a mass lesion (tumor), rather than presenting as an acute infection.
Tuberculosis has become resistant to many antibiotics and multi-resistant strains are
emerging. Treatment of active cases of tuberculosis involves the use of three or four
antibiotics for prolonged periods.
Transmission
Tuberculosis is spread primarily by airborne droplets expelled during coughing or sneezing
by a person with untreated pulmonary or laryngeal tuberculosis. Infectious droplets may
remain suspended in the air for several hours.
Close contacts of persons with undiagnosed and/or untreated pulmonary tuberculosis are
at high risk of being infected. Close contacts are those living in the same household,
close friends or fellow workers. About 29% of close contacts become infected.
May 2005
Page 2
TG 645
Infectiousness varies depending on the duration and intensity of exposure. Persons in the
same household, especially those sharing a bedroom, are at highest risk of infection. See
table, below.
New infection can usually be detected by tuberculin skin testing six weeks following the
initial exposure.
SEE CDC CRITERIA FOR DETERMINING INFECTIOUSNESS, BELOW.
Patients with suspected or proved pulmonary TB should be considered infectious if they:
are coughing, or
are undergoing cough-inducing procedures, or
have sputum smears positive for AFB
AND they
have not completed 2-3 weeks of adequate therapy, or

have a poor clinical response to therapy, or
continue to have sputum smears positive for AFB
Patients are not considered infectious if they meet all of these criteria:
have received adequate therapy for 2-3 weeks,
have a favorable clinical response to therapy, and
3 consecutive sputum smears on different days are negative for AFB
3. PREVENTION
Transmission of infection is through contact with active cases and can be reduced by:
Identifying and treating the close contacts of a person with active disease.
Identifying newly infected persons by performing periodic tuberculin skin testing.
Prompt use of appropriate anti-tuberculosis drugs.
Avoiding face-to-face contact with persons suspected of having active TB and who are
coughing.
Adequate ventilation of rooms in which active cases are being treated.
High levels of hygiene such as washing hands and utensils, sterile spirometry equipment,
etc.
4. SCREENING FOR TUBERCULOSIS

The purpose of screening is to identify cases of inactive (and occasionally active)
tuberculosis by determining the tuberculin skin test status.
Peace Corps applicants are tested prior to service to establish a baseline TB skin test
measurement , i.e., size of reaction, if any, in mm. Applicants with evidence of TB
infection will be evaluated to rule out active disease and be considered for preventive
therapy as per CDC guidelines (see section 5.)
May 2005
Page 3
TG 645
All Volunteers are screened for TB at Close of Service (COS). Volunteers are also
screened at mid-service, if clinically indicated. Use of multiple-puncture techniques
(Tine tests) and/or self-reporting of reactions by Volunteers is allowed only at midservice and only when unable to observe Volunteers 48-72 hours after testing. See
section 4.2.
Volunteers who were identified TB skin test positive during the pre-service screening
in the U.S. should not be tested at the mid-service health evaluation or at COS. Routine
chest x-rays are not necessary as long as they remain asymptomatic.
Volunteers reporting symptoms suspicious of TB or who have had close contact with a
person who has active TB must be TB skin tested.
Some Volunteers may have had BCG vaccination in their past. It is OMS policy to
disregard a history of BCG vaccination when interpreting TB skin test results if the
BCG was performed more than five years prior to the TB test. If a Volunteer has had a
BCG vaccine within 5 years of the TB skin test, PCMOs should consult OMS for
guidance on test interpretation.
4.1
Classification of inactive tuberculosis

Persons with a positive TB skin test may be classified as converters if they have had a
documented negative TB skin test within the past two years. This assumes that the
previous test was correctly done and correctly interpreted. When done correctly, this
allows identification of those who are most likely to have been infected recently and
who would most benefit from preventive therapy. Preventive therapy is indicated for
converters, regardless of age (see section 5.)
Persons with a positive TB skin test who have not been tested in the past two years or
who have a documented positive TB skin test previously may be classified as reactors.
Volunteers who are TB skin test reactors are identified during pre-service testing and
those who meet criteria for preventive therapy are started on therapy before starting
service overseas (see section 5.)
4.2
Performing the test
The Mantoux test (intradermal test) is required to accurately measure the size of the
TB skin test reaction. It must be administered and measured by the PCMO or other
trained provider. The Mantoux test is required at COS and is strongly encouraged
at mid-service, however multiple puncture testing may be done at mid-service if
unable to arrange for direct observation of the Mantoux test.
The Mantoux test should be performed by the intradermal injection of 0.1 ml of

PPD tuberculin containing five (5) TU (tuberculin units) on the volar surface of the
forearm.
The injection should be made with a disposable tuberculin syringe, inserted just
beneath the surface of the skin on the volar (inner) aspect of the forearm. The
injection is made with the needle bevel facing upward to produce a discrete, pale
elevation of the skin (a wheal) 6 mm to 10 mm in diameter. Do not compress the
wheal. Deeper injection (into the subcutaneous tissues) will produce false negative
test results.
May 2005
Page 4
TG 645
How to read the test:
The Mantoux test is read 48 to 72 hours after the injection. The reading should be
based on measurement of induration (hardness), not erythema (redness). The
diameter of induration should be measured across the long axis of the forearm and
must be recorded in millimeters.
The preferred method of reading a Mantoux test is to use a ball-point pen placed
about an inch from the center of the injection site. Draw a line toward the center,
stopping when the tip of the pen reaches an area of resistance (which indicates
induration.) Continue drawing lines from all quadrants towards the center.
Measure the longest axis of induration and record in the health record. See below.
Measure
longest
axis
Injection
site
Volunteers must not be expected to read the Mantoux test. Only PCMO-observed
test results are acceptable. If it is necessary to screen for TB using the Tine test (at
mid-service only), follow the recommendations listed below.
If a Volunteer fails to return within 72 hours but does return within 7 days and has a
positive test (see flowchart), the test result can be accepted and documented in the
health record. Negative test results obtained more than 72 hours after injection
must be repeated.
Document the result of the skin test in millimeters in the progress notes in the
Volunteer health record. It is insufficient to simply indicate a positive or
negative test result.
Use of Tine testing during the mid-service health evaluation
If Mantoux testing cannot be performed at mid-service, multiple-puncture (Tine)

testing using PPD may be used to screen for potential TB skin test reactions. The
Mantoux test must be used to confirm a suspected reaction.
To increase the sensitivity of the Tine test when read by the Volunteer, the
following criteria should be used:
Check the test site daily. Report ANY redness, swelling, or firmness that is present
after 48-72 hours to the PCMO. The size of the reaction is not important. ANY
REACTION PRESENT AFTER 48-72 HOURS IS SIGNIFICANT and may mean
that infection with TB is present.
May 2005
Page 5
TG 645
A postcard or other reminder, which includes the statement presented above, is

recommended. Standard Tine test postcards are not designed for this purpose and
should not be used. Volunteers who fail to return the postcard should be retested at
the next opportunity, preferably by Mantoux testing.
Any reaction reported by the Volunteer must be follow up by Mantoux testing and
reading by the PCMO or other health provider. PCMOs are strongly encouraged to
become proficient in TB skin testing and to avoid allowing testing by other
providers unless they can demonstrate expertise in both applying and measuring the
test.
In areas where TB is highly endemic and where mid-service testing using the
Mantoux test is not feasible, it is reasonable to perform a Mantoux test on
Volunteers who are in the capital for other reasons and who havent had a Mantoux
test in at least 6 months. This will permit Mantoux testing of many Volunteers in
addition to Tine testing of all Volunteers at mid-service. IST events may provide
another opportunity to perform Mantoux testing.
WHEN IN DOUBTREPEAT THE MANTOUX TEST
4.3
For example, Mantoux testing may be repeated to confirm a positive test performed
by another provider or to recheck a test which was difficult to read.
Volunteers who were vaccinated with BCG in the past should be TB skin tested
and, if positive, treated with preventive therapy (following the protocol described in
section 5.)
Interpreting the results

For Volunteers serving overseas, an increase in size of the TB skin test reaction
(induration) of 10mm is considered positive. A flowchart is provided below to aid in
interpreting the TB (Mantoux) skin test. Note that for Volunteers in certain high risk
situations (e.g., close contact of an active TB patient) the criteria for a positive TB skin
test is modified to be an increase in size of 5mm.
The exact criteria, which defines a positive test, varies according to the likelihood of
TB exposure, i.e, risk group and the probability of developing active TB. For
example, HIV infected persons are considered to be TB skin test positive if their skin
test is at least 5 mm, while healthy persons in the U.S. are considered positive if the test
is 15 mm or greater.
EXAMPLE 1:
A Volunteers pre-service and mid-service TB skin test measured 0 mm.

At COS, a TB skin test reaction of 12 mm was noted. This is considered
a positive test (>10 mm increase in size from prior test done within 2
years.) Preventive therapy is indicated (see section 5.)
EXAMPLE 2:
A Volunteer has a 7 mm TB skin test at mid-service. His pre-service TB

skin test was reported to be negative (assume it was 0 mm.) He states
that one of the adults in his household was diagnosed as having TB
earlier this year. This is considered a positive test. Preventive therapy
is indicated (see section 5.)
May 2005
Page 6
TG 645
EXAMPLE 3:
A Volunteers pre-service TB skin test measured 4 mm and was

considered negative. At mid-service a TB skin test reaction of 12 mm
was found (increase in size of 8 mm.) She gives no history of close
contact with a person known to have TB, and is otherwise healthy. This
is considered a negative test (less than 10 mm increase over prior test.)
Preventive therapy is not indicated.
For Volunteers serving overseas, the TB skin test is considered positive if the interval
change in induration is:
5 mm and the Volunteer is in any of the following high risk groups:
Persons with known or suspected HIV infection

Recent contacts of a TB case
Persons with fibrotic changes on CXR consistent with old TB
Persons with organ transplants or other immunosuppressive disease
10 mm and the Volunteer in the high risk groups listed above or any of the following high
risk groups:
Recent arrivals from high-prevalence countries
Injection drug users
Residents and employees of high-risk congregate settings, e.g., correctional
facilities, nursing homes, homeless shelters, hospitals
Mycobacteriology laboratory personnel
Persons with clinical conditions that make them high risk, e.g., substance
abuse, diabetes, etc. See Table A, Section 5.1 below.
15 mm
All Volunteers
May 2005
Page 7
TG 645
INTERPRETATION OF TB SKIN TESTING

FOR PEACE CORPS VOLUNTEERS
Ask about symptoms of TB
(cough, wt. loss, fever, night swears, etc.)
Measure area of
induration, if any
* Perform TB skin testing

annually for all Volunteers
except those with a
documented positive test
in the past.
Determine increase in size from

previous test if within 2 years
0-4 mm increase?
Symptoms of TB
present?
OR
Close contact of
active case?
YES
10 mm increase?
5-9 mm increase?
Any one of these:

Symptoms of TB?
Close contact of active case?
Known or suspected HIV infection?
NO
TB infection
unlikely
Obtain CXR
Consult OMS
Chest x-ray findings of old TB,

inadequate or no treatment?
NO
YES
TB infection likely
TB infection
unlikely
Consider:
Exclude Active Disease
Retest in 3 months
(close contacts)
1. Obtain chest X-ray

2. Assess symptoms- productive cough?
3. Close contact of active case?
4. HIV test if at risk for HIV infection
5. Obtain sputum if productive cough
(see text)
False negative skin test

(active TB, HIV,
immunospressed)
Inactive TB
recent converter
TB Preventive Therapy
indicated
(see Section 5)
May 2005
Active Tuberculosis
Consult OMS
Page 8
TG 645
5. TB PREVENTIVE THERAPY
Preventive therapy with isoniazid (INH) greatly reduces the risk of developing active
disease. Persons determined to be at risk of developing active TB are candidates for
preventive therapy regardless of age.
Prior to Peace Corps service, applicants are required to have a TB skin test. Those who
qualify for TB preventive therapy as defined by the CDC/American Thoracic Society are
required to start therapy prior to service.
5.1
Indications for Isoniazid (INH) Preventive Therapy

Indications for preventive therapy during service: Volunteers serving overseas are, by
definition, at higher risk of TB infection. Preventive therapy is indicated for all
Volunteers who become TB skin test positive (recent converters) regardless of age.
Indications for preventive therapy pre-service: The indications for starting preventive
therapy for Peace Corps applicants are more complex. CDC/ATS criteria are used
during pre-service medical clearance to identify those who will benefit from preventive
therapy. Applicants meeting these criteria are required to begin therapy prior to
receiving medical clearance. The CDC/ATS criteria are included here for reference.
Candidates for Treatment of Latent TB Infection (LTBI)

CDC/ATS criteria for the use of preventive therapy regardless of age.
Positive skin test result 5 mm
Persons with known or suspected HIV infection
Recent contacts of a TB case
Persons with fibrotic changes on CXR consistent with old TB
Persons with organ transplants or other immunosuppressive disease
Recent arrivals from high-prevalence countries
Injection drug users
Residents and employees of high-risk congregate settings, e.g., correctional
facilities, nursing homes, homeless shelters, hospitals.
Mycobacteriology laboratory personnel
Persons with clinical conditions that make them high risk, e.g., substance abuse,
diabetes, etc. See page 10.]
Persons with no known risk factors.
May 2005
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TG 645
Table A
Table B
Medical Conditions Associated with Increased Risk

of TB Disease
Persons at Increased Risk

of TB Exposure
HIV infection
Close contacts of a person with infectious TB
Recent TB infection (within 2 years)

History of inadequately treated TB
Persons from areas where TB is common (e.g. Asia,

Africa, Latin America)**
Substance abuse (especially injectable drug use)
Medically underserved, low income populations
CXR findings suggestive of previous TB (with

history of inadequate or no treatment)
The elderly
Certain medical conditions:
Residents of long-term facilities (e.g., correctional

facilities, nursing homes)
Low body weight (more than 10% below ideal)
Persons who inject drugs
Diabetes
Groups identified locally as having an increased

prevalence (e.g., migrant farm workers, homeless
persons)
Silicosis
Prolonged corticosteroid therapy
Other immunosupressive therapy
Persons who may have occupational exposure to

TB**
Intestinal bypass or gastrectomy

Chronic malabsorption syndrome
** PEACE CORPS VOLUNTEERS
Cancer of the head and neck

Hematologic/reticuloendothelial system diseases
(leukemia, lymphoma)
End-stage renal disease
5.2
Persons at higher risk for adverse effects of INH

INH may not be indicated for Volunteers who: (consult OMS if present)
5.3
have a history of previous INH associated hepatic injury or other adverse reaction
have acute or active liver disease
currently are abusing alcohol or injecting drugs (provide close monitoring)
have or are at risk for peripheral neuropathy
are pregnant (generally delay INH until after delivery)
are likely to be infected with INH-resistant M. tuberculosis
are highly unlikely to complete therapy (e.g., some homeless persons)
Starting INH preventive therapy

Baseline laboratory testing is not routinely indicated for all patients at the start of
treatment for LTBI. Baseline hepatic measurements of serum AST (SGOT) or ALT
(SGPT) and bilirubin are indicated for patients whose initial evaluation suggests an
increased risk for liver disease.
Prior to initiating INH preventive therapy, PCMOs should exclude active TB with a
chest x-ray and possibly sputum examination (if coughing) and other tests as symptoms
warrant.
May 2005
Page 10
TG 645
Begin treatment with INH 300 mg daily for at least 9 months (12 months if
immunosupressed). Nine months of INH is more effective than 6 months. The
Office of Medical Services recommends that 9 months of therapy be used wherever
possible. Medical Officers should consult OMS if a Volunteer is unable to
complete 9 months of therapy.
Pyridoxine 25mg daily (vitamin B6) should be given to reduce the risk of peripheral
neuropathy
Dispense one month of medication at a time unless it is impractical for the

Volunteer to return monthly and there are no special concerns about INH toxicity.
Always arrange for monthly contact (see section 5.4.)
Advise the Volunteer to avoid alcohol or acetaminophen use.
If conversion is discovered at COS, give the Volunteer one month of medication

with instructions to see a physician in the U.S. by the end of the month (unless
traveling after COS*- see below.)
** INH should not be started if monthly follow up by telephone or, when necessary, by
an office visit and liver enzyme monitoring is not possible. For example, an
asymptomatic Volunteer who is found to be TB skin test positive at COS and who
plans on traveling in developing countries for several months should not be started
on INH until after return to the U.S.
5.4
Monitoring INH preventive therapy

Monitoring for compliance is especially important for persons on preventive therapy
because they do not have symptoms related to their infection. The incidence of INH
hepatotoxicity varies with age. Serious hepatotoxicity occurs in about 1% of persons
above age 35 and 2% above age 50. Mild, transient liver enzyme elevations occur in
10-20% of persons taking INH. The most recent CDC/ATS recommendations include
monthly liver enzyme monitoring for persons 35 years of age or older. This may not be
practical in some situations (see below.)
Volunteers on preventive therapy should be monitored monthly by questioning for:
Compliance with the prescribed regimen.
Symptoms of neurotoxicity such as paresthesias of hands or feet.
Signs consistent with liver damage such as loss of appetite, nausea, vomiting,
persistent dark urine, yellowish skin, malaise, or unexplained elevated temperature
of greater than 3 days duration and abdominal tenderness (especially right upper
quadrant).
Use the TB Medication Monthly Symptom Checklist to document monthly follow-up.

(See ATTACHMENT A)
If liver transaminase tests (ALT, AST) are determined to be clinically indicated,

and the results are elevated (more than three times normal) or symptoms of an
adverse effect are reported, stop INH and consult OMS.
May 2005
Page 11
TG 645
Refer to the TB Preventive Therapy flowchart (below)
TB PREVENTIVE THERAPY FLOW CHART

Assess for Contraindications to INH
Previous INH-associated hepatic injury

History of severe adverse reactions to INH
Acute or active liver disease
Alcohol abuse
ALSO: Suspected INH resistance

NO
YES
Able to provide 9
months of follow-up?
(see text)
NO
Delay INH until after

return to the U.S.
Consult OMS
YES
Treat for 9-12* months with INH

Provide medication 1 month at a time
Avoid alcohol and acetaminophen
Follow-up monthly for symptoms of INH toxicity
* complete at least 9 months of therapy,

9 months is preferred whenever possible
(12 months is recommended for persons
with HIV infection)
6. ACTIVE TUBERCULOSIS
Refer to the Clinical Presentation and Management of Active Tuberculosis (below)

OMS will determine if an active case of tuberculosis is to be managed in-country and will
advise on initiating multi-drug therapy.
Initiate multi-drug regimen for initial control after consultation with OMS.
Initiate respiratory precautions by providing adequate ventilation (5 or 6 room air

changes per hour) and ensuring that the ill PCV covers the mouth and nose when
coughing, laughing, or sneezing. Dispose of tissues promptly. Ultraviolet lights may kill
bacilli in the upper air of a room.
Monitor for response to treatment bacteriologically through sputum culture at least

monthly until conversion to negative (see instructions for taking a sputum sample.) A
positive sputum culture is the only definitive sign of treatment failure or relapse. Sputum
that remains culture positive beyond 3 months of therapy should suggest the possibility
of disease due to drug-resistant organisms or failure of the patient to take medications as
prescribed.
May 2005
Page 12
TG 645
Initiate a contact investigation. Identify the Volunteers close contacts and inform them
that they should be tested for TB. If close contacts are Volunteers, skin test them, if they
have positive skin tests treat them as converters. Notify local authorities, if appropriate.
Monitor monthly for adverse reactions to anti-TB medications.
Non compliance is a major problem as drug resistance may develop if medications are
not taken consistently and for a long enough period of time. Assess compliance of the
PCV, and count pills regularly. (See attached TB Medication Monthly Symptom
Checklist.) Follow-up missed appointments.
CLINICAL PRESENTATION AND MANAGEMENT OF ACTIVE TUBERCULOSIS

Subjective:
History of exposure to persons with potentially active TB, such as working in a hospital, a
household contact or close friend known to have TB, known cases occurring at work such as a
school.
Symptoms include anorexia, easy fatigability, weight loss, chilly sensations, afternoon remittent
fever, productive prolonged cough, bloody sputum and night sweats.
Obtain a history of exposure to tuberculosis, previous tuberculosis infection or clinically active

disease.
Objective:
Physical findings are not specific. Auscultation of the lungs may appear normal.
Perform Mantoux skin test. The PCMO must read this result personally. (The skin test may be
negative in a person with active TB disease.)
Obtain a chest x-ray, posterior-anterior view.
Obtain an erythrocyte sedementation rate (ESR)
Obtain a series of 3 early morning sputum specimens (see obtaining a sputum specimen) for acidfast bacilli (AFB) stain and TB culture. This is the most definitive diagnostic test!
Culture results normally take 2 weeks if broth media is used and 3 to 6 weeks for conventional
solid media. AFB smear results are available quickly. Request drug susceptibility tests for culture
if available. WHO labs with trained personnel may be available in-country.
Assessment:
Consult OMS for a differential diagnosis. If sputum smear is AFB negative it may need to be
repeated. Abnormalities on chest x-rays are suggestive of, but are never diagnostic for,
tuberculosis. Definitive diagnosis may require medical evacuation to a more advanced facility.
Respiratory precautions are necessary when TB is strongly suspected. AFB smear positive
patients are the most infectious, and should generally complete 14 days of treatment with several
drugs and be AFB smear negative before travel is considered.
May 2005
Page 13
TG 645
SPUTUM SAMPLE COLLECTION
Clean and thoroughly rinse the mouth with water.
Breathe deeply three times (you should have a tickling feeling at the end of
a very deep breath).
After the third breath, cough hard and try to bring up sputum from deep in
the lungs.
Expectorate the sputum into a sterile container, collecting at least one
teaspoonful.
REFERENCES
American Thoracic Society (1994) Treatment of Tuberculosis and Tuberculosis Infection in

Adults and Children, American Journal of Respiratory and Critical Care Medicine. 149,
1359-1374.
Centers for Disease Control (1990) Screening for Tuberculosis and Tuberculosis Infection in
High-Risk Populations and The Use of Preventive Therapy for Tuberculosis Infection in
the United States, Morbidity and Mortality Weekly Report Recommendations and
Reports. 39, No. RR-8, 1-12.
National Tuberculosis Training Initiative (2000) Core Curriculum on Tuberculosis. Fourth
Edition. Centers for Disease Control and Prevention.
May 2005
Page 14
TG 645 ATTACHMENT A
TB Medication Monthly Symptom Checklist

Name of PCV: ________________________________
Date therapy started: ____/____/_____

Todays date:
1. Are you using alcohol (circle one) often
occasionally
rarely
not at all
Do you have any of the following complaints?

Y/N ____
1.
Loss of appetite
Y/N ____
2.
Nausea
Y/N ____
3.
Vomiting
Y/N ____
4.
Malaise
Y/N ____
5.
Dizziness
Y/N ____
6.
Headaches
Y/N ____
7.
Yellow eyes
Y/N ____
8.
Burning, numbness or tingling of hands or feet
Y/N ____
9.
Dark urine
Y/N ____
10. Yellowish skin
Y/N ____
11. Tenderness over liver (upper right quadrant of abdomen)
Y/N ____
12. Elevated temperature
13. If the answer to any of the above is Yes, please describe:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
14. Number of pills left in bottle: ____________
Completed by: _____________________________________
15. Number of pills dispensed: ________________
16. Type of TB medication: ____ INH _____ Rifampin ____ Other
17. Number of months completed: ________
18. Next visit date: ____/____/____
PCMO Signature: ___________________________________ Date: ____/____/____
____/____/_____

Peace Corps MTG 605 FOIA General Medicine Nurse

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Peace Corps

Technical Guideline 605

Office of Health Services

4. MEDICAL TECHNICAL GUIDELINES (TGs)

Office of Health Services

6. RESPONSIBILITIES OF THE RN PCMO

Office of Health Services

8. RESPONSIBILITIES OF THE DIRECTOR/OFFICE OF MEDICAL (D/OMS) SERVICES OR DESIGNEE

e. Patient Specific Standing Orders (PSSO)

physician are granted by the D/OMS.

Office of Health Services

Urticaria, hypotension, bronchospasm (asthma), laryngeal

Accelerated ( 1-72 hrs )

Urticaria, morbilliform eruptions, laryngeal edema

Late ( 3-7 days )

Urticaria, skin rashes, drug fever, serum sickness like reactions

Very late ( > 1 week )

Hemolytic anemia, thrombocytopenia, granulocytopenia,

Antibiotics (penicillins, cephalosporins, sulfonamides, vancomycin)

Hypertonic solutions (contrast media, e.g. for IVP)

Insect bites and stings

Foreign proteins, preservatives and stabilizers (gamma globulin, immunizations)

Foods (esp: peanuts, seafood, eggs)

Airborne allergens (pollens, molds, danders)

Office of Medical Services

Anti-inflammatory drugs (aspirin, ibuprofen, etc.)

Volunteers are screened to identify those at risk of severe allergic reactions.

Give drug orally rather than parenterally when possible

Medical records must be updated to include newly identified drug allergies.

Supplies Necessary To Treat Anaphylaxis

DIPHENHYDRAMINE HCL (Benadryl) for IM/IV use

Office of Medical Services

IV SOLUTION (Four (4) 500ml containers of D5 Normal saline)

BLOOD PRESSURE CUFF and STETHOSCOPE

Precautions Concerning Epinephrine

Underlying cardiovascular disease

Coexisting use of beta blockers

Office of Medical Services

Intravenous or Intratracheal Epinephrine

3-5 ml of epinephrine for IV administration (1:10,000 concentration), or

Prepare a dilution of 1ml standard epinephrine (1:1000) in 10 ml saline,

Vasopressors (Dopamine, etc.)

Office of Medical Services

Dopamine Rapid Reference Chart

6. MEDICAL CLEARANCE IMPLICATIONS

CLINICAL PRESENTATION AND TREATMENT OF ANAPHYLAXIS

Office of Medical Services

Cardiovascular (tachycardia, hypotension, shock)

Respiratory (laryngeal edema, stridor, tachypnea, dyspnea, wheezing, cough)

Skin (pruritus (itching), cutaneous flushing, angioedema)

Gastrointestinal (nausea, vomiting, diarrhea, abdominal pain)

Eye and nose (tearing, sneezing, rhinorrhea)

Neurologic (anxiety, weakness, syncope)

Primary medical disorder (seizure, MI, hypoglycemia, dehydration, sepsis)

As the progression of anaphylaxis is unpredictable, appropriate treatment should begin

Follow treatment algorithm - ATTACHMENT A

Moving the patient:

Observation after the acute phase:

Use of IV epinephrine, dopamine, or other vasoactive drugs:

Office of Medical Services

(angioedema, severe bronchospasm,

(urticaria, mild bronchospasm)

(airway obstruction-laryngeal edema

Maintain or establish airway