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Athugh PhiHeath is t i theusiess f devepig ciica practice

guideies (CPGs), it has paed a criticare i prtig the devepet

ad utiizati f CPGs the edica speciat

societies. At present, PhilHealth has identied the

fwig ciica practice guideies that ca serveas asis fr quait assurace ad accreditati:

cuit-acquired peuia (CAP) i aduts

ad i chidre, astha i aduts ad i chidre,uriar tract ifecti i aduts ad i chidre,hpertesi, acute rchitis, acute gastreteritis,

dspepsia, degue herrhagic fever, cataract,diaetes eitus, ra sptaeus deiver,

chronic cough in children, rst simple febrile

seizure, checstitis, ad acute appedicitis.

PhilHealth initiatives in CPG implementation,spearheaded by the HTA Committee, fall into threemain categories.

Educatia itervetis

PhilHealth has provided logistical support tothe development of the cataract guideline by thePhilippine Academy of Ophthalmology (PAO) and tothe Philippine Society of Microbiology and InfectiousDisease (PSMID) guideline working groups. As a resultof this support, the cataract guideline has been includedin the National Guideline Clearinghouse in the US.PSMID produced its CPGs on urinary tract infection(UTI), community-acquired pneumonia in adults andtuberculosis in adults.

PhilHealth has also conducted oral presentationsto promote guidelines during several PMA regional

conferences. The CPGs that were presented were thePhilippine Heart Association guideline on hypertension,the PSMID guideline on UTI and CAP. Copies of the guidelines were distributed by PhilHealth to theparticipants.

PhilHealth has also published the HTA Forum topromote evidence—based medicine. Health technology assessments, which are systematic evidence-based

evaluations of the safety, effectiveness, and efciency of medicines and procedures, have been regular featuresof the Forum. These assessments have been used by PhilHealth to select drugs and procedures for insurancecoverage. By publishing them, PhilHealth intends tohelp improve the quality of health care provided to itsmembers and to provide guidance to doctors, hospitalsand patients about the reimbursability of specic drugs,

TheHTA Forum

Volume 04 No.1 2006

The Ofcial Publication of the Health Technology Assessment Unit

Quality Assurance Research and Policy Development Group

Perfrace Reprt PhiHeath Use f CPGsfr Quait Assuracead Accreditati

•PhilHealth Policy Statements on the Ten 3Commonly Claimed Illnesses

•Pediatric Community Acquired Pneumonia 4

•Acute Appendicitis 6

•Hypertension 7

•Dyspepsia 8

•Acute Bronchitis 8

•Adult Asthma 9

•Community Acquired Pneumonia in Adults 11

•Urinary Tract Infection 12

•Acute Gastroenteritis 14

•Maternity Care 15

INSIDE THIS ISSUE

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tests and procedures. This canpotentially minimize the number of denied claims.

Accreditati

PhilHealth policies have consistently supported guideline use. ThePhilHealth BenchBook, released in2005 and set for implementation in2007, requires guideline utilization.Standard 2.4.1 requires that“clinical pathways derived fromclinical practice guidelines and othertypes of clinical evidence should bedeveloped or implemented for thetop 10 cases of admissions and/orconsultations.” In addition, standard

7.2 requires that “resources fordeveloping or adopting clinicalpractice guidelines are provided”by the hospital.

The PhilHealth BenchBook isconsistent with the principles of evidence-based health care set forthby the National Health Insurance Act. For example, the Act requiresthat health care providers participatein and conduct health technology

assessments in the selectionand implementation of healthinterventions in order to promotequality and cost-effectiveness. Inturn, the BenchBook requires that“new processes of care are designedcollaboratively based on scienticevidence, clinical standards, cultural values and patient preferences(standard 7.2)”. Currently,preparation for implementationof the BenchBook consists of two

main strategies.

PhilHealth systems accrediting andsurveying hospitals are undergoing enhancements and capacity building.On the other hand, hospitals andhealth care providers have beenfamiliarizing and capacitating themselves to comply with thenew BenchBook accreditationstandards.

Cais reiurseet

Incorporating measures of CPG

compliance to claims payment isan ongoing PhilHealth initiative.Guideline recommendations thatare based on Grade A evidence(See Tables indicated per guideline)have been converted into medical

review criteria (MRCs) and Policy Statements.

MRCs are statements that areused to measure performanceand determine compliance withstandards. These performancestandards are based on therecommended tests, medicines,procedures and other interventionscontained in CPGs. The MRCs will be used to review claims and

approve payments.

Policy Statements are based onkey CPG recommendations andprovide guidance to doctors,hospitals and patients as to whattests, medicines and proceduresare strongly recommended to beprovided if their benets clearly outweigh the harms. There are alsonegative Policy Statements basedon negative CPG recommendations

when some tests, medicines andprocedures have been found to beuseless or even harmful. Policy Statements also advise the publicregarding the reimbursability of tests, medicines and procedures. This issue of the HTA Forum isdevoted to these Policy Statements.

In October 2000, PhilHealth adoptedthe Positive List of Drugs basedon the Grade A recommendations

of the CAP, UTI and HypertensionCPGs. The List expanded thecoverage of medications eligiblefor reimbursement. A before andafter study by Dr. Valera et. al in2002 found that, in governmenthospitals, utilization of the drugson the Positive List slightly increased after the policy took effect. In contrast, a decrease inutilization of these drugs wasnoted in private hospitals. Overall,the percentage of compliance with clinical practice guidelinesfor pneumonia and hypertension

Edoal AdvsoBoad

Edoal Boad

JoseAcuin,MD

NoelEspallardo,MD

MarioFestin,MD

JonathanFlavier,MD

KennethHartigan-Go,MD

NoelJuban,MD

CarloIrwinA.Panelo,MD

AgnettePeralta,MSc

MadeleineValera,MD

ClementineBautista,MD

AnitaSangalang,MD

MelanieSantillan,MD

MarcAnthonyCepeda,MD

RonaldPaguirigan,MD

MerlaRoseDavid,RPh

AristidesTacang

Ma.SophiaVarlez

ArnulfoA.Nisperos

Philippine Health Insurance

Corporation

CityStateCentre709ShawBlvd.,Pasig

City1600

Website:www.philhealth.gov.phE-mailAddress:

[email protected]

FranciscoT.Duque,III,MD

LornaO.Fajardo

Honorary Chairpersons

DavidBanta,MD

RowenaDaroyMorales,Llb

SadasivanSivalal,MD

JaimeGalvez-Tan,MD

MichaelLimTan,PhD

Edoal Saff

2

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increased after the Positive List wasadopted. This increase was notedfor both government and privateinstitutions. A follow-up study using interrupted time series andsegmented regression showed thatprescribing patterns of PhilHealth-accredited physicians generally hadconformed with the local clinicalpractice guideline recommendationsfor the management of community acquired pneumonia. In general,the implementation of the policy expanding the drug coverage forpatients admitted with community acquired pneumonia did notsignicantly change prescribing patterns of PhilHealth-accreditedphysicians.

The Positive List has sinceexpired. However, the NationalHealth Insurance Act empowersPhilHealth to expand the list of essential drugs in the PhilippineNational Drug Formulary (PNDF)from time to time. This expandedlist will be based on the results of the health technology assessments

that PhilHealth regularly conducts.

CPG Dissemination Program

PhilHealth will be disseminating 10 CPGs this year and conducting guideline promotion activitiesin selected hospitals in MetroManila and provinces. The Policy Statements of the 10 CPGs that will be disseminated are featured inthis issue of the HTA Forum.

Following dissemination, PhilHealth will regularly review the claims that will be led by the participating hospitals for adherence to the CPGs. The results of this review will be fedback to the hospitals themselves.Reports of this demonstrationproject will be featured in futureissues of the HTA Forum.

The clinical practice guidelines(CPGs) for the most commonreimbursable claims in PhilHealthare featured in this issue of theHTA Forum. PhilHealth employs

a 5 stage process in selecting theten CPGs. Initially, the processinvolves a systematic search forCPGs published locally and abroad.Retrieved CPGs are screened forrelevance to PhilHealth needsand validity of methods. Tocheck validity, PhilHealth usesthe AGREE Instrument, aninternational validated guidelineappraisal tool, as well as anappraisal checklist developed in-

house. Specic recommendationson disease assessment, laboratory tests, drug treatments andadmission policies are thenextracted from the screened CPGsand assessed for applicability tolocal settings. The technical staff of the Quality Assurance Researchand Policy Development Group(QARPDG) under the supervisionof the Health Technology Assessment Committee (HTAC)

makes all guideline appraisals.Lastly, to be consistent with theexisting National Health Insurance

PhiHeath PicStateets the TeC CaiedIesses

Act, the drugs that arementioned in the nal setof recommendations areonly those that are in the6th edition of the PNDF. All PhilHealth endorsedguidelines are in publicdomain, although local

specialty societies thatdeveloped the

selected guidelines havealso been contacted.

A te the HTA Cittee

The process of selecting theCPGs is conducted by the Quality Assurance Research and Policy

Development Group (QARPDG)of PhilHealth with oversight by the HTAC. The QARPDG isheaded by Dr. Madeleine R. Valeraand is supervised by the PhilHealth Vice President for Health FinancePolicy and Services Sector, Dr.Eduardo P. Banzon.

The HTAC was set up in 1998to conduct health technology assessments and advise

PhilHealth in the selection of health technologies for insurancecoverage. Since then, the HTAChas also conducted training workshops for PhilHealth on CPGappraisal and implementationusing PhilHealth accreditation andclaims reimbursement to enhanceprovider adherence to CPGs. All PhilHealth activities that aimto promote the adoption andutilization of CPGs are planned,

implemented and evaluated withthe technical assistance of theHTAC.

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Ciica Diagsis

In a coughing child, look for thefollowing signs:

TAblE 1

AGE SIGNS

3 months Tachypnea and/or chest

to 5 years indrawing (Grade B) 2

5 to 12 years Fever, tachypnea,

crackles (Grade D) 2

Beyond 12 Fever, tachypnea,

years tachycardia and at least

one abnormal chest ndingsofdiminished

breath sounds, rhonchi,

crackles or wheezes

(Grade D) 2

Hspita Adissi

Cassif patiets risk f dig(see Tae 2). PCAP C ad D

patiets a e hspitaized.[Grade D]2 PCAP A and B patients

can be managed on an outpatient basis.[Grade D]2

VARIABLES PCAPA PCAPB PCAPC PCAPD

Minimalris Lwris Mderateris Highris

1. Co-morbid illness None Present Present Present

2. Compliant caregiver Yes Yes No No

3.Abilitytofollow-up Possible Possible Notpossible Notpossible

4.Presenceof None Mild Moderate Severe

dehydration

5.Abilitytofeed Able Able Unable Unable

6. Age >11 mo >11 mo <11 mo <11 mo

7. Respiratory rate

2-12 months <50/min >50/min >60/min >70/min

1-5 years <40/min >40/min >50/min >50/min

> 5 years <30/min >30/min >35/min >35/min

8.Signsofrespiratoryfailure

a.retraction None None Intercostal/Supraclavicular/

subcostal intercostal/subcostal

b. head bobbing None None Present Present

c. cyanosis None None Present Present

d. grunting None None None Present

e. apnea None None None Present

f.sensorium None None IrritableLethargic/stuporous/

comatose

9. Complications None None Present Present

[effusion,

pneumothorax]

ACTIONPLAN OPD OPDAdmittoregularAdmittocritical

Follow-upatendFollow-upafter ward careunit

oftreatment 3days Refertospecialist

TABLE2.RISkCLASSIfICATIoNfoRPNEuMoNIA-RELATEDMoRTALITy[LEVEL5](PPS,2004)

PEDIATRIC CommUnITy ACQUIRED

PnEUmonIA (PCAP)

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Diagstic Tests

Chest x-ra [Grade b, leve 2]2 ad white d ce cut [GradeC, leve 4]2 a e requested frhspitaized patiets.

When indicated, culture and sensitivity of blood, pleural uid, tracheal aspirate,and blood gas and/or pulse oximetry may be requested for hospitalizedpatients. [Grade D, leve 5]2

No routine ESR or CRP. [Grade A,leve 1]2 No routine examinationsfor non-hospitalized patients. [GradeD]2

Treatet

Fr PCAP A r b patiets withut previus atiitic, give raaxicii (40-50 mg/kg/day in3 divided doses for an average of 7days). [Grade D]2 Alternative drugsinclude cotrimoxazole, chloramphenicol,erythromycin or formulary macrolides.

Fr PCAP C patiets, give peicii G (100,000 units/kg/day in 4 divided doses) or apicii (100 mg/kg/day in 4 divided doses).[Grade D]2 Alternative drugs includechloramphenicol, cefuroxime andampicillin-sulbactam.

n cugh preparatis eeded.

mitrig Respse t Iitia Therap

Look for symptom resolution. [GradeD, leve 5]2

n fw-up as eeded. [GradeD, leve 5]2

Streaiig Atiitic Therap

In selected patients, switch to oraltherapy when signs of infection areresolving after 2-3 days. [Grade D,leve 5]2 These are patients who show symptom resolution, ability to feed andabsence of complications.

Supprtive Care/Aciar Treatet

Among inpatients, oxygen andhydration may be given if needed.[Grade D, leve 5]2

No routine chest physiotherapy,

bronchial hygiene, nebulization withnormal saline solution, steam inhalation,

topical solution, bronchodilators andherbal medicines. [Grade D]2

Hspita Discharge

PCAP C or D patients may bedischarged when they improve and arere-classied as PCAP A or B. These arepatients with stable vital signs for ageand ability to maintain oral intake.1

References (Search Date: August 2005)

1. PhilHealth Health Technology Assessment Committee. Proceedings of Workshop on the Critical Appraisal of Clinical Practice Guidelines and Development of Policy Statements. September 19-21, 2005.

2. Philippine Pediatric Society (PPS). Clinical Practice Guideline in the Evaluation and Management of Pediatric Community Acquired Pneumonia (Immunocompetent Filipino Children Aged 3 months to 19 years). 2004.

GRADELEVELof THERAPy DIAGNoSIS

EVIDENCE

A 1a Systemat icreview[SR]withhomo- SRwithhomogeneityof level 1diagnost ic

geneityofrandomizedcontrolled studiesoracl inicalpracticeguidelinevalidated

trials [RCT] on a test set

1b Individualrandomizedcontrolled Independentblindcomparisonofanappropriate trialwithnarrowcondenceinterval spectrumofconsecutivepatients,allofwhom

have undergone both the diagnostic test and the

referencestandard

1c Allornone SpPinandSnNout*

B 2a SRwithhomogeneitycohort SRwithhomogeneityoflevel> 2 diagnostic

studies studies

2b Individual cohort study [including Independent blind comparison but either in non-

lowqualityRCTe.g.<80follow-up] consecutivepatientsorconnedtoanarrow

spectrumofstudyindividuals[orboth],allof

whom have undergone both the diagnostic test

andthereferencestandard;oradiagnostic

clinical practice guideline not validated in a test

set.

2c “Outcomes” research

3a SRwithhomogeneityofcasecontrol studies

3b Individualcasecontrolstudy Independentblindcomparisonofanappropriate

spectrumbutreferencestandardwasnotapplied

to all study patients

C 4 Caseser iesandpoorqual itycohor t Referencestandardwasnotappl iedindepen-

dently or not applied blindly

D 5 Expert opinion Expert opinion

TABLE3.GRADESofRECoMMENDATIoNANDLEVELSofEVIDENCE(PPS,2004)

*SpPin: When a sign/test/symptom has high Specifcity, a Positive result rules in the diagnosis.

SnNout: When a sign/test/symptom has high Sensitivity, a Negative result rules out the diagnosis.

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Ciica Diagsis

Prged right wer quadrat pai ad tederess with a durati f at east 7-12 hurs a suggest acuteappedicitis. [Cat. A, leve I]3 In children, pain andtenderness may not be localized. [Grade D]1

Diagstic Tests

White d ce with differetia cut a e requested.[Cat. A, leve I]3

Abdominal CT scan, abdominal ultrasound or diagnosticlaparoscopy for equivocal appendicitis may be requested withproper justication. [Cat. A, leve I ad II]3

Pai adia x-ra, ariu eea, ad scitigraphare t receded. [Cat. A, leve II]3 No routine gramstain and culture/sensitivity of intra-operative specimens.[Cat. A, leve II]3

Treatet

Appedect is the apprpriate treatet fr acuteappedicitis. [Cat. A, leve II]3

Fr UnComPlICATED acute appedicitis, thefwig atiitics a e used fr surgica

prphaxis: [Cat. A, leve I]3 Cefxiti (2 grams IV singledose for adults or 40 mg/kg IV single dose for children),apicii-suacta (1.5-3 grams IV single dose for adultsor 75 mg/kg IV single dose for children), or getaici 80-120 mg IV single dose pus cidaci 600 mg IV singledose for adults or gentamicin 2.5 mg/kg IV single dose plusclindamycin 7.5-10 mg/kg IV single dose for children).

Fr ComPlICATED acute appedicitis, the fwigatiitics a e used with cst csiderati:[Cat. A, leve I]3 Tazobactam-piperacillin, ciprooxacinplus metronidazole (for adults), imipenem-cilastatin (forchildren), or gentamicin plus clindamycin.

For post-operative pain management, acetaminophen [GradeS]1, ibuprofen [Grade S]1, ketorolac [Grade C & E]1, andmorphine [Grade S]1 may be used.

Hspita Discharge

A patient may be discharged when fully recovered fromanesthesia, afebrile for 24 hours, tolerates a regular diet,

achieves pain control on oral medication, and for complicatedacute appendicitis, has suitable home environment to assurepost-op antibiotic administration.2

References (Search Date: September 2005)

1. Cincinnati Children’s Hospital Medical Center (CHMC).Evidence-Based Clinical Practice Guideline for Emergency Appendectomy. 2002.

2. PhilHealth Health Technology Assessment Committee. Proceedings of Workshop on the Critical Appraisal of Clinical Practice Guidelines and Development of Policy Statements. September 19- 21, 2005.

3. Philippine College of Surgeons (PCS). Evidence-Based Clinical Practice Guidelines on the Diagnosis and Treatment of Acute Appendicitis. 2002.

CATEGoRy DESCRIPTIoN

A Recommendations that were approved by consensus (at least

75%ofthemultisectoralpanel)

B Recommendations that were somewhat controversial and did

not meet consensus

C Recommendations that cause real disagreements among the

membersofthepanel

TABLE4.STRENGTHofRECoMMENDATIoNSANDLEVELS

ofEVIDENCE(PCS,2002)

LEVEL DESCRIPTIoN

I EvidencefromatleastoneproperlydesignedRCTormeta-

analysis

II Evidencefromatleastonewelldesignedclinicaltrialwithout

properrandomization,fromcohortorcase-controlledanalytic

s tudies(preferablyonecenter) ,f rommultiple time-series,or

fromdramaticresultsinuncontrolledexperiments

III Evidencefromopinionsofrespectedauthoritiesonthebasisof c linica lexper ience, descriptivestudies,or repor tsof exper t

committees

TABLE5.LEVELSofEVIDENCE(PCS,2002)

GRADE DESCRIPTIoN

A Randomized controlled trial: large sample

B Randomized controlled trial: small sample

C Prospective trial or large case series

D Restrospective analysis

E Expert opinion or consensus

S Review article

M Meta-analysis

TABLE6.GRADESofRECoMMENDATIoN(CHMC,2002)

ACUTE APPEnDICITIS

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Ciica Diagsis

Hpertesi is csidered i a patiet with bP f 140/ 90 Hgr higher, recorded on at least twooccasions. It may be classied as stage1 (SBP = 140 – 159 or DBP = 90 – 99)or stage 2 (SBP > 160 or DBP > 100).3

Diagstic Tests

Fastig d gucse, seru ptassiu, creatiie, ad uriasis

are receded. [Grade A]2

When indicated, 12-lead ECG,hematocrit, calcium, lipoproteinprole may be requested. For patients

with diabetes or kidney disease, themeasurement of urinary albuminexcretion/albumin creatinine ratiomay also be included in the routinelaboratory tests. Appropriate diagnosticprocedures may be considered toidentify causes of HPN among patients in whom there is a high indexof suspicion (age, history and physical

examination, severity of hypertension,and initial laboratory ndings aresuggestive of specic causes) andamong patients who respond poorly todrug therapy.3

Hspita Adissi

Patiets with hpertesiveeergecies shud e aditted ithe hspita. 3

Patients with hypertensive urgencies,or those with upper levels of Stage

II hypertension associated withsevere headache, shortness of breath,epistaxis or severe anxiety may also beadmitted.1

HyPERTEnSIon

Treatet

Fr hpertesi stage I withutcpeig idicati, thiazidediuretics are the priar drugs f chice. 3

A secd drug, either as a separate prescription or in xed-doseciatis with thiazide diureticsa e used whe the bP reaisuctred or when BP is >20mmHg above systolic goal or 10 mmHg above diastolic goal, These includeloop and potassium-sparing diuretics,

aldosterone receptor blockers, beta-blockers, ACE inhibitors, angiotensinII antagonist, calcium channel blockers,alpha I blockers, central alpha IIagonists, direct vasodilators, additionalcombination drug: ACEI + CCB. 3

For hypertension with compelling indications the following may be used:3

a. Diuretics – heart failure, high coronary disease risk, diabetes, recurrent stroke prevention

b. Beta-blockers – post-MI, heart failure, high

coronary disease risk, diabetes c. ACE Inhibitor – heart failre, high

coronary disease risk, diabetes, recurrent stroke prevention, chronic kidney disease, post MI

d. Angiotensin Receptor Blocker – heart

failure, diabetes, chronic kidney disease

e. Calcium Channel Blocker – high coronary disease risk, diabetes

f. Aldosterone Antagonist – heart failure, post-MI

The following formulary parenteraldrugs may be used for hypertensiveemergencies: vasodilators (Nanitroprusside, nicardipine HCl,nitroglycerin, hydralazine HCl) andadrenergic inhibitor (esmolol HCl).3

Patients with hypertensive urgenciesmay be given oral short-acting agent

such as captopril and clonidine followedby several hours of observation.3



2. Philippine Society of Hypertension (PSH).The Philippine Clinical Practice Guidelines on the Detection and Management of Hypertension. 1996.

3. The Seventh Report of the Joint National Committee on Prevention, Detection,Evaluation and Treatment of High Blood Pressure. 2003.

GRADE DESCRIPTIoN

A The recommendation is based on one or more studies at level 1

B The best evidence available is at level 2

C The best evidence is at level 3

D The best evidence available is lower than level 3, and included experts’opinions, clinical experience and common sense. These recommend-ations

addresspracticalissuesofimplementationandotherfactorsexistinginthe

TABLE7.GRADESofRECoMMENDATIoN(PSH,1996)

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Ciica Diagsis

To diagnose dyspepsia, the following symptoms should besought: chric r recurret epigastric discfrt r pai

with atedess, gawig r urig sesati, moreprominent at daytime, for at least two (2) weeks. [Grade A]2

Hspita Adissi

Connement is not usually needed.3

Treatet

Treat with a prt-pup ihiitr, a prkietic aget fr2-4 weeks. H2-blocker, sucralfate and antacids may be usedas alternative. [Grade A]2


1. American Gastroenterological Association (AGA). Evaluation of Dyspepsia. 1998.

2. The Family Medicine Research Group (FMRG) and the Department of Family and Community Medicine Consensus Panel, UP-PGH.Clinical Practice Guideline for the Management of Dyspepsia in Family Practice.1998.

3. PhilHealth Health Technology Assessment Committee. Proceedings of Workshop on the Critical Appraisal of Clinical Practice Guidelines and Development

Ciica Diagsis

Cugh fr e week prductive f puruet sputu may suggest a diagnosis of acute bronchitis.[ Grade A]1 Fever,chills, difculty of breathing, easy fatigability and hoarsenessmay suggest other conditions.2

Hspita Adissi

Connement is not usually needed.2

Diagstic Tests

n rutie a tests are needed for uncomplicated acutebronchitis.2

o mitrig Respse t Therap

Prognosis is good and special monitoring or referral for

specialty care is not required. [Grade C]1

Treatet

n atiitics are needed for uncomplicated acute bronchitis.[Grade C]1

Ihaed rchdiatrs may be given. [Grade A]1


1.The Family Medicine Research Group (FMRG) and the UP-PGH Department of Family and Community Medicine Consensus Panel.Clinical Practice Guideline for the Management of Acute Bronchitis

in Family Practice. 2000.2.PhilHealth Health Technology Assessment Committee. Proceedings of

Workshop on the Critical Appraisal of Clinical Practice Guidelines and Development of Policy Statements. September 19-21, 2005.

GRADE DESCRIPTIoN

A Good evidence to support the recommendation that the option be

specicallyconsidered.Therecommendationwasmadebasedonat

least one level I published evidence.

B Fair evidence to support the recommendation that the option be specicallyconsidered.Therecommendationwasmadebasedonat

least one level II published evidence.

C Poorevidenceregardinginclusionorexclusionoftheoption,butthe

recommend-ation was made on other grounds (experts’ opinion,

consensus panel, or committee reports)

D Fair evidence to support the recommendation that the option be

specicallyexcludedfromtheconsideration.Therecommendation

was made based on at least one level II published evidence.

E Good evidence to support the recommendation that the option be

specicallyexcludedfromtherecommendation.Therecommendation

was made based on at least one level I published evidence.

TABLE8.GRADESofRECoMMENDATIoNfoRDySPEPSIA(fMRG,1998)

DySPEPSIA

GRADE DESCRIPTIoN

A Good evidence to support the recommendation that the option be


least one level I published evidence.

B Fair evidence to support the recommendation that the option be


least one level II published evidence.

C Poorevidenceregardinginclusionorexclusionoftheoption,butthe

recommend-ation was made on other grounds (experts’ opinion,

consensus panel, or committee reports)

D Fair evidence to support the recommendation that the option be

specicallyexcludedfromtheconsideration.Therecommendationwas

made based on at least one level II published evidence. E Good evidence to support the recommendation that the option be

specicallyexcludedfromtherecommendation.Therecommendation

was made based on at least one level I published evidence.

TABLE9.GRADESofRECoMMENDATIoNfoRACuTE

BRoNCHITIS(fMRG,1998)

ACUTE bRonCHITIS

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Ciica Diagsis

To make a diagnosis of asthma, thefollowing should be sought in thepatient’s history : ad ff cughthat gets wrse at ight, wheezig,dspea ad chest tightess often aggravated by exposure to allergens,irritants, exercise, and viral infections, ahistr f astha i the fai, adiprveet f cditi with the

use f ati-astha edicatis.

1

Diagstic Tests

ojective easures [Grade A]2 ike Frced Expiratr Vuei 1 secd (FEV

1), Peak

Expiratr Fw Rate, ad airwahperrespsiveess are needed todiagnose asthma.

Treatet

Cassif a patiets with asthaaccrdig t severit to helpdetermine the need for therapy ( See Table 12 )2

For Formulary Treatment of Asthmasee Table. (See Table 14)

The following medications may beadministered to patients with acuteasthmatic attacks:

* Ihaed ß2–agists [Grade A]2

* Ssteic r ra sterids [Grade A]2

* Ihaed ipratrpiu ride +

ihaed ß2–agists [Grade A]2

The following medications maybeadministered to patients with persistetastha:

* Ihaed crticsterids [Grade A]2

* Fixed dse ciati f g-actig ß2–agists adihaed crticsterids to controlsymptoms and improve lung

function. [Grade A]2

Hspita Adissi

Patients with status asthmaticus andthose who do not respond to treatmentof acute asthmatic attacks in theemergency room should be admitted.

Long term treatment of asthma can bestarted while the patient is still admittedin the hospital.1

GRADE DEfINITIoN

A TherecommendationisbasedononeormorestudiesatLevelI

B Thebestevidenceavai lable is atLevel I I

C ThebestevidenceisatLevelIII

D The best evidence available is lower than 3, and include experts’ opinions, clinical experience, and

commonsense.Theserecommendationsaddresspracticalissuesofimplementationandother

factorsexistinginthelocalsetting.

TABLE10.GRADESofRECoMMENDATIoN(PCCP,2004)

LEVEL DEfINITIoN

1 All5ofthefollowingcriteriaaresatised:

a.Therewasanindependentinterpret-ationoftheresultsofthediagnostictest(withoutknowledge

oftheresultsofthegoldstandard).

b.Therewasanindependentinterpret-ationoftheresultsofthegoldstandard(withoutknowledge

oftheresultsofthediagnostictest).

c. Thestudypatientsconsistedofpatients(butnotknown)tohavethedisorderofinterest.

d.Thediagnostictestandgoldstandardarebothdescribedinsufcientdetailtoallow

reproducibility.

e.Thestudypopulationconsistsofatleast50patientswithand50patientswithoutthedisorderof

interest.

2 4ofthe5criteriaaremet

3 3ofthe5criteriaaremet.



6 Noneofthe5criteriaaremet.

-

TABLE11.LEVELSofEVIDENCE(PCCP,2004)

ADUlT ASTHmA

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Hspita Discharge

Patients with stable vital signs for 24

hours and have the ability to maintainoral intake may be discharged.1



2. Philippine College of Chest Physicians (PCCP) Council on Asthma. Philippine Consensus Report on Asthma Diagnosis and Management. An Evidence-based

Update. 2004.3. Philippine College of Chest Physicians

(PCCP) Council on Asthma. Philippine Consensus Report on Asthma Diagnosis and Management. 1996.

SeveritRecmmendedtreatment

Dailcntrllermedicatins Alternativecntrller Relievermedicatins

Intermittent Noneneeded SABAasneeded

MildtoModeratePersistent ICS+LABAcombinationassingle ICShighdoseorICSregulardose+ SABAasneeded

inhaler anyoftheff:

-SRTheophylline

-Antileukotriene

-OralSRß2-agonist

SeverePersistent Oralsteroids+ICS+LABAcombination SABAasneeded

assingleinhaler+anyoftheff:

-SRTheophylline

-Antileukotriene

-OralSRß2-agonist

TABLE13.TREATMENTBASEDoNASTHMASEVERITy(PCCP2004)

PARAMETER

Severit

IntermittentPersistent

Mild-Mderate Severe**

Daytimesymtoms Monthly Weekly Daily

Nocturnalawakening Lessthanmonthly Monthlytoweekly NIghtly

Rescueß2

-agonistsuse Lessthanweekly Weeklytodaily Severaltimesaday

PEF or FEV1* >80%pred. 60-80%pred. <60%pred.

Treatment needed to control asthma Occasional prn ß2-agonistsonly RegularICS+LABAcombination CombinationICS+LABA+OCS

TABLE12.NEWCLASSIfICATIoNofCHRoNICASTHMASEVERITy(PCCP,2004)

GenericName

Inhaledcorticosteroid+LABA Budesonide+Formoterol

Fluticasone+SalmeterolInhaled Corticosteroid Beclomethasone Dipropionate

Budesonide

Fluticasone

OralCorticosteroid Methylprednisolone

Prednisone

Anti-leukotrienes Montelukast

Mastcellstabilizer Nacromoglycate

Bronchodilator Controllers

LABA

Inhaled Formoterol

Salmeterol

Procaterol

Oral Formoterol

Procaterol

Salbutamol

Terbutaline

Xanthine derivative Theophylline

Bronchodilator Relievers

SABA

Inhaled Salbutamol

Terbutaline

SABA

Oral Salbutamol

Terbutaline

Anti-cholinergic Ipratropiu

Anti-cholinergic+SABA Ipratropium+Fenoterol

Ipratropium+SalbutamolXanthine derivative Theophyllne

Anti-infammatory Controllers

TABLE14.foRMuLARyDRuGSfoRTHETREATMENTofASTHMA(PCCP,2004)

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Ciica Diagsis

Cough, fever, difculty of breathing,ad/r chis within the past 24 hoursto less than 2 weeks [A-II]1, 5 associated

with tachpea (RR > 20 breaths/min), tachcardia (CR > 100/min),and fever (T > 37.8’C) with at least oneabnormal chest nding of diiishedreath suds, rhchi, crackes r

wheeze [Grade B]6 suggest community-acquired pneumonia.

Diagstic Tests

Chest x-ra is receded fra patiets ciica diagsedf peuia [A-II/Grade A ]3,6

Gram stain and culture of appropriate

pulmonary secretions [Grade A]6

andpretreatment blood cultures [A-II]3 may be requested when drug resistance issuspected and for etiologic diagnosis.

Hspita Adissi

Cassif patiets risk categriest hep deterie the eed frhspitaizati. o derate adhigh-risk CAP shud e aditted.[GRADE A]6 (See Table 15)

Treatet

Iitia epiric therap based on initialrisk stratication is recommended.[Grade B]6 Among patients withidentied etiologic agent, appropriateantimicrobials should be instituted.3 (See Table 16).

mitrig Respse t Iitia Therap

Look for symptom resolution. Fw-up chest x-ra is t eeded. [Grade A]6

CommUnITy

ACQUIRED

PnEUmonIA

In ADUlTS

Stablevitalsigns Unstablevitalsigns: Anyoftheclinicalfeatureof

*RR<30breaths/min *RR>30breaths/min moderateriskCAPplusanyof

*PR<125beats/min *PR>125beats/min thefollowing:

*SBP>90mmHg *Temp> 40’C or < 35’C

*DBP> 60 mmHgNoorstablecomorbidconditions Unstablecomorbidcondition(i.e. shockorsignsofhypoperfusion

Noevidenceofextrapulmonary uncontrolled diabetes mellitus, *hypotension

sepsis active malignancies, progressing * altered mental state

Noevidenceofaspiration neurologic disease, congestive *urineoutput<30mL/hr

Chest x-ray: heart failure (CHF) Class II-IV, hypoxia (PaO2

< 60 mmHg) or

*Localizedinltrates unstable coronary artery disease, acute hypercapnea

*Noevidenceofpleuraleffusion renal failure on dialysis, uncom- (PaCO2

> 50 mmHg)

nor abscess pensated COPD, decompensated Chest x-ray:

*Notprogressivewithin24hrs liver disease) * as in moderate risk CAP

Evidenceofextrapulmonarysepsis

(hepatic, hematologic, gastrointes-

tinal, endocrine)

Suspectedaspiration

Chest x-ray:

*Multilobarinltrates

*Pleuraleffusionorabscess

*Progressionofndingsto>50%in

24 hrs

These patients are sitabler These patients needtbehspi- These patients warrant admissin

tpatientcare [GradeA]6 talizedrparenteraltherap intheintensivecarenit

[GradeA]6 [GradeA]6

LwRisCAP MderateRisCAP HighRisCAP

TABLE15.CLINICALfEATuRESofPATIENTSWITHCAPACCoRDINGToRISk(PSMID,2004)

ANTIBIoTIC DoSAGE ANTIBIoTIC DoSAGE

LoWRISkCAP

(all taken orally)B-lactams:

Amoxicillin

Trim/sulfonamide:

Cotrimoxazole

Macrolides

Azithromycin

Clarithromycin

500 mg TID

160/800 mg BID

500 mg OD

500 mg BID

B-lactams w/ B-lactamaseinhibitor:

Co-amoxiclav

Sultamicillin

2 nd gen. Cephalosporins

Cefuroximeaxetil

625 mg TID or 1 g BID

750 mg BID

500 mg BID

MoDERATERISkCAP

Macrolides

Erythromycin IV

Azithromycin PO or IV

Clarithromycin PO or IV

GatioxacinPOorIV

B-lactams w/ B-lactamase

inhibitor :

Sulbactam-AmpicillinIV

0.5-1 g q 6h

500 mg q 24h

500 mg q 12h

400 mg q 24h

1.5 g q 8h

2 nd gen. Cephalosporins

CefuroximeIV

CefoxitinIV(w/anaerobic

activity)

3rd gen. Cephalosporins

CeftriaxoneIV

CefotaximeIV

1.5 g q 8h

1-2 g q 8h

1-2 g q 24h

1-2 g q 8h

HIGHRISkCAP

(all routes are IV)

Macrolides

Erythromycin

Azithromycin

Clarithromycin

Gentamicin

Netilmicin

Tobramycin

B-lactams w/ B-lactamase

inhibitor :

Sulbactam-Ampicillin

0.5-1 g q 6h

500 mg q 24h

500 mg q 12h

3 mg/kg q 24h

7 mg/kg OD

3 mg/kg q 24h

1.5 g q 6-8h

3rd gen. Cephalosporins

Ceftriaxone

Cefotaxime

Ceftizoxime

Anti-pseudomonal B-lactams:

Ceftazidime

Cefepime

Ticarcillin-clavulanate

Piperacillin-tazobactam

Sulbactam-cefoperazone

Imipenem

MeropenemOthers:

Oxacillin

Clindamycin

Metronidazole

1-2 g q 24h

1-2 g q 8h

1-2 g q 8h

2 g q 8h

2 g q 8-12h

3.2 g q 6h

2.25-4.5 g q 6-8h

1.5 g q 12h

500 mg q 6h

1-2 g q 8h

1-2 g q 4-6h

600 mg q 8h

500 mg q 6-8h

TABLE16.uSuALRECoMMENDEDDoSAGESoffoRMuLARyANTIBIoTICSIN50-60kBWADuLTSWITHNoRMALLIVERANDRENALfuNCTIoNS(PSMID,2004)

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GRADE DEfINITIoN

A Good evidence to support a

recommendationforuse

B Moderateevidencetosupporta

recommendationforuseC Poor evidence to support a

recommendationfororagainstuse

D Moderateevidencetosupporta

recommendation against use

E Good evidence to support a


TABLE18.GRADESofRECoMMENDATIoN(PSMID,2004)

Cefuroxime

Cexime

Co-amoxiclav

Sultamicillin

Azithromycin

Clarithromycin

Gatioxacin

Moxioxacin

500 mg BID

100-200 mg BID

1 g BID750 mg BID

500 mg OD

500 mg BID

400 mg OD

400 mg OD

Antibitic Dsage

TABLE17.ANTIBIoTICDoSAGEofoRALAGENTSfoRSTREAMLININGoRSWITCH

THERAPy(PSMID,2004)

STRENGTHOFRECOMMENDATION




recommend-ationforuse

C Poor evidence to support a

recommendation





QUALITYOFEVIDENCE

I Evidencefrom> 1 properly random-

ized, controlled trial

II Evidencefrom> 1 well-designed

clinicaltrial,withoutrandomization;

fromcohortorcasecontrolledana-

lyticstudies(preferablyfrom>one

center);frommultipletime-series;or

fromdramaticresultsofuncontrolled

experiments

III Evidencefromopinionsofrespected

authorities, based on clinical experi-

ence, descriptive studies, or reports

ofexpertcommittees

CATEGoRy,

GRADE

DEfINITIoN

TABLE19.IDSAGRADINGSySTEMfoRRATINGRECoMMENDATIoN(IDSA,2003)

Supprtive Care

Oxygen, hydration, and antipyreticsmay be given if needed.5

Streaiig epiric atiitic

therap

In selected patients, switch t ratherap when signs of infection areresolving within 72 hours. [Grade A]3 (See Table 16)

Hspita discharge

Patients with stable vital signs for 24hrs and able to maintain oral intakemay be discharged.

[Grade B]6

References (Search Date: August 2005)

1. Bartlett JG, Dowell SF, Mandell LA et al. Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults. Infectious Diseases Society of America. Clin Infect Dis Aug 2000; 31(2):347-82.

2. Field MJ, Lohr KN, Eds. Clinical Practice Guidelines: Directions for a New Program. Institute of Medicine 1990

3. Mandell, LA, et al. Infectious Diseases Society of America. Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults. Clin. Infect Dis. Dec 1, 2003. 37(11):1405-33.

4. Niederman MS, Mandell LA, Anzueto A et al. Guidelines for the Management of Adults with Community-Acquired Pneumonia. Diagnosis, Assessment of Severity, Antimicrobial Therapy and Prevention. Am J Respir Crit Care Med June 2001; 163(7):1730-54.


6. Philippine Society of Microbiology and Infectious Diseases, Inc. (PSMID)Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and Prevention of Community-Acquired Pneumonia in Immunocompetent Adults 2004 Update.

Ciica Diagsis

To make a clinical diagnosis of urinary tract infection, one or moreof the following should be soughtin the patient’s history : dsuria,

frequency, hematuria, fever, ank

URInARy TRACT

InFECTIon pai, wer adia pai,aset vagia discharge, aset

vagia irritati, ad ack pai.6

UTI shud e categrized ase f the fwig: cstitis,

peephritis, asptaticacteriuria, recurret UTI,cpicated UTI. 6

Diagstic Tests

Rutie uriasis is t eededt diagse UTI.

Urinalysis or urine gram stain may be requested for the following conditions: acute uncomplicatedpyelonephritis [Grade b]6, acutecystitis in pregnant women [GradeC]6, and acute uncomplicated cystitisin women with gynecological (vaginal)signs and symptoms [Grade b]6,and uncomplicated cystitis in men.

[Grade C]6

2

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Urie cuture ad sesitivit may berequested for patients with worsening signs and symptoms [Grade C]6, forscreening asymptomatic bacteriuriaamong pregnant women [Grade b]6,

for acute uncomplicated pyelonephritis,acute pyelonephritis in pregnancy andsuspected complicated UTI. Follow-up urine culture is not necessary for patients clinically responding totherapy. [Grade C]6

Renal ultrasound and plain abdominalX-ray should be done only in thepresence of gross hematuria during UTI episode, obstructive symptoms,clinical impression of persistentinfection, infection with urea-splitting bacteria, history of pyelonephritis,history of or symptoms suggestive of urolithiasis, history of childhood UTI

and elevated serum creatinine. [GradeC]6

Blood culture should only be consideredif with sepsis. [Grade C]6

Hspita Adissi

Hspitaizati is t eeded[Grade C]6 except

* In acute uncomplicatedpyelonephritis in women who areunable to accept oral hydration

or oral medications; or withcomplications such as sepsis;

* In acute pyelonephritis in pregnant women;

* In complicated UTI;

* In urinary candidiasis patients whoare: under critical care, neutropenic,post-renal transplant, or about toundergo neurological procedures.

Treatet

Antibiotic management depends on theinitial and denitive UTI condition. 5

Fr id t derate cpicatedUTI, oral uoroquinolones arereceded. [Grade A]6

Ampicillin and amoxicillin should notbe used. [Grade E]6

Any of the antibiotics listed in Table21 and Table 22 can be used for UTIdepending on local susceptibility patterns and host factors.

DEfINITIoN

A Good evidence to support a recom-

mendationforuse

B Moderateevidencetosupportarecommendationforuse

C Poor evidence to support a recom-

mendationfororagainstuse



E Good evidence to support a recom-

mendation against use

CATEGoRy,

GRADE

TABLE20.GRADESofRECoMMENDATIoN(PSMID,2004)

ANtiBiOticS DOSE, FrEquENcyOrAL

Ooxacin 400 mg BID

Ciprooxacin 500 mg BID

Gatioxacin 400 mg OD

Cexime 400 mg OD (only 100 &

200 mg capsule are in

6th ed of PNDF)

Cefuroxime 500 mg BID

Co-amoxiclav 625 mg TID

PArENtErAL (gven nl paen s

afeble)

Ceftriaxone 1-2 gm Q 24

Ciprooxacin 200-400 mg Q 12

Gatioxacin 400 mg Q 24

Gentamicin 3-5 mg/kg BW (+/- ampi-

cilin) Q 24

Ampi- 1.5 gm [when gram stain

sulbactam shows gram (+)

organisms] Q6

Piperacillin- 2.25 – 4.5 gm Q 6-8

tazobactam

TABLE21.EMPIRICTREATMENTREGIMENSfoRuNCoMPLICATEDACuTEPyELoNEPHRITIS

(PSMID2004)[GRADEA]

DOSE, FrEquENcy DurAtiONOrAL

Ciprooxacin 250-500 mg BID 14 days

Ooxacin 200 mg BID 14 days

PArENtErAL (gven nl paen s afeble)

Ampicillin 1 gm q 6 hrs + gentamicin 3 mg/kg/day q 24h

Ampi-sulbactam 1.5 gm – 3 gm q 6h

Ceftazidime 1-2 gm q 8h

Ceftriaxone 1-2 gm q 24h

Imipenem-cilastatin 250-500 mg q 6-8h

Piperacillin-tazobactam 2.25 gm q 6h

Ciprooxacin 200-400 mg q 12h

Ooxacin 200 - 400 mg q 12h IV

ANtiBiOticS

TABLE22.ANTIBIoTICSTHATMAyBEuSEDASEMPIRICTHERAPyfoRCoMPLICATEDuTI(PSMID2004)[GRADEB]


1. American College of Radiology - Medical Specialty Society. ACR Appropriateness Criteria for Imaging in Acute Pyelonephritis. www.guideline.gov . August 2005

2. American College of Radiology - Medical Specialty Society. ACR Appropriateness Criteria for Recurrent Lower Urinary Tract Infection in Women. www.guideline. gov August 2005

3. Institute for Clinical Systems Improvement - Private Nonprot Organization.

Uncomplicated Urinary Tract Infection in Women. www.guideline.gov . July 2004

4. Orenstein R and Wong ES. Urinary Tract Infections in Adults. American Family Physician. March 1999; 59(5).http://www.aafp.org/afp/990301 ap/1125.html


6. Philippine Practice Guidelines Group in

Infectious Disease Task Force on Urinary Tract Infections Philippine Society for Microbiology and Infectious Diseases. The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults. CPGvol. 2 number 1 update 2004.

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Ciica Diagsis

Acute gastroenteritis is diagnosed inpatients presenting with chages ithe character ad frequec f stad ae accpaied sigsf dehdrati. [A-II]1

ACUTEGASTRoEnTERITIS

Hspita Adissi

Patients with severe dehdrati, as we as patiets wh reai t havese dehdrati despite iitiatreatet ad a chid with ddiarrhea ad severe autritishud e aditted.3

Diagstic Tests

Fecasis may be done in patients

admitted for acute gastroenteritis. 2

For patients not responding to standardtreatment, selective fecal studies may be requested.3

Knowing the levels of serum electrolytes

rarely changes the management of children with diarrhea. 3

Treatet

ORS solution and IV uids are thestandard treatment for dehydrationcaused by diarrhea and these areadministered based on the degree of dehydration. 3

Zic at a dose of 10-20 mg/day may be given for 10-14 days to all children

with diarrhea.3

Malnourished children or children whodevelop diarrhea during or shortly aftermeasles may be given ra vitai A at a dose of 200,000 units/dose andagain the next day: 200,000 units/dosefor age 12 months to 5 years, 100, 000units for age 6 months to 12 months,and 50,000 units for age less than 6months. 3

Antiemetics, cardiac stimulants, bloodor plasma, steroids, or purgatives are notrecommended in acute gastroenteritis.3

CAuSE ANTIBIoTIC(s)ofCHoICEa ALTERNATIVE(s)

Chlerab,c Dxccline Erthrmcin

Adults: 300 mg once, or Children: 12.5 mg/kg

Tetraccline 4 times a day x 3 days

Children: 12.5 mg/kg Adults: 250 mg4 times a day x 3 days 4 times a day x 3 days

Adults: 500 mg

4 times a day x 3 days

Shigelladsenterb Ciprofoxacin Pivmecillinam

Children: 15 mg/kg Children: 20 mg/kg

2 times a day x 3 days 4 times a day x 5 days

Adults: 500 mg Adults: 400 mg

2 times a day x 3 days 4 times a day x 5 days

Cetriaxne

Children: 50-100 mg/kg

onceadayIMx2to5day

Amebiasis Metrnidazle

Children: 10 mg/kg


(10daysforseveredisease)Adults: 750 mg


(10daysforseveredisease)

Giardiasis Metrnidazled

Children: 5 mg/kg


Adults: 250 mg


TABLE23.THEfoLLoWINGANTIMICRoBIALSMAyBEADMINISTEREDToSELECTEDPATIENTSWITHDIARRHEA[WHo,2005]

DEfINITIoN




recommend-ationforuse

C Poor evidence to support a

recommendationfororagainstuse


recommend-ation against use



GRADE

TABLE24.GRADESofRECoMMENDATIoN

4

a. All doses shown are for oral administration. If drugs are not available in liquidform for use in young children, it may be necessary to use tablets and estimate thedoses given in this table.

b. Selection of an antimicrobial should be based on sensitivity patterns of strains of Vibrio cholerae O1 or O139, or Shigella recently isolated in the area.

c. An antimicrobial is recommended for patients older than 2 years with suspectedcholera and severe dehydration.


1. Infectious Diseases Society of America.Practice Guidelines for the Management of Infectious Diarrhea. 2001.

2. PhilHealth Health Technology Assessment Committee. Proceedings of Workshop on the Critical Appraisal of Clinical Practice Guidelines and Development of Policy Statements. September 19-21, 2005

3. World Health Organization. The Treatment of Diarrhea: A Manual for Physicians and Other Senior Health Workers. 2005.

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AnTEnATAl CARE

The following interventions are

recommended at all visits:

bd pressure easureet isrecommended for all pregnant womenat each prenatal visit following theguidelines of National High BloodPressure Education Program.4

mid t derate exercise 3 or moretimes per week during pregnancy isrecommended for all healthy pregnant

women.4

mitrig f weight gai inpregnant women should be assessed

every visit.4

The use f tacc ad ach should be screened at 6-8 weeks

AOG.4

Immunization status for tetaustxid booster should be determinedat the initial prenatal visit. If there isno documentation of Td booster

within the last ten years, Td booster

should be provided. There are nocontraindications other than a previoussevere reaction to Td vaccination, suchas anaphylaxis, generalized urticaria, or

angioedema.4

Hepatitis b surface antigendeterminationshould be doneat the initialprenatal visit.4

R o u t i n eu r i a s i s

should be doneat the initialprenatal visit asscreening forasymptomaticbacteriuria.4

Testing for themajor dgrups Abo is

recommended during the rst antenatal visit.3

Rutie screeig fr Sphiis during pregnancy is recommendedusing non-treponemal serologic test

VDRL or RPR.3

Measurement of fudic height starting at 18 weeks AOG until thethird trimester is recommended atevery prenatal visit.4

Auscultation of feta heart suds starting at 20 weeks AOG is

recommended at every prenatal visit.

4

Universal screening of pregnant womenfor gestatia diaetes eitus(GDm) using the 50-gram GlucoseChallenge Test between 24 and 28

weeks’ gestation is recommended. Atest value > 140 mg/dl or 7.8 mmol/li for plasma glucose is consideredelevated.3

Pregnant women with signs andsymptoms of preterm labor like

low, dull backache, menstrual-likecramps, abdominal cramping (may beassociated with diarrhea) and four ormore uterine contractions per hour

should be educated.4

All pregnant women should beinstructed to perform dai fetaveet cutig starting at thethird trimester of pregnancy.4

The patients’ with the following pastedica histr are recommended forreferral to physician on rst visit.4

Past OB/GYN History:Prior preterm delivery (<37 weeks)Intrauterine fetal demise (IUFD) – 10

weeks with no cardiac activity Prior cervical/uterine surgery Prior preterm labor requiring admission (e.g., early cervicalchange)Fetal anatomic abnormality (e.g.,open neural tube defects in priorchild or rst degree relative)Past complicated pregnancy

Medical History:Pre-existing diabetesGestational diabetesHIV Chronic hypertensionSystemic disease that requiresongoing care (e.g., severe asthma,lupus, and inammatory boweldisease)Current mental illness requiring medical therapy Cancer

Seizure disordersHematologic disordersRecurrent urinary tract infections/stones

Psycho-Social:Substance use disordersEating disordersPostpartum depression

Conditions in Current Pregnancy:Age (<16 or >35 years at delivery)Vaginal bleeding

InTRAPARTUm CARE

Iterittet auscutati isrecommended for monitoring fetal

15

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mATERnITy CARE

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for Normal Labor and Delivery. TaskForce on Clinical Practice Guidelines in the Management of Normal Labor and Delivery. 2002.

3. Task Force on Philippine Guidelines on Periodic Health Examination.Philippine Guidelines on Periodic Health

Examination, Effective Screening for Diseases among Apparently Healthy Filipinos. 2004.

4. Veterans Health Administration,Department of Defense. Clinical Practice Guideline for the Management of Uncomplicated Pregnancy. 2002

5. World Health Organization, Standards for Maternal and Neonatal Care,Department of Making Pregnancy Safer.

well being during normal labor. [leveI-b]2

There is eed fr restrictif fd except in situations whereintervention is anticipated. Routine IV infusion is not recommended during

labor. [leve II-b]2

Rutie eea is t receded during early labor. [leve I-E]2

Rutie shavig f periea area ist receded prior to delivery. [leve I-E]2

The routine use of aesthesia adaagesia is t part of the careduring delivery. [leve I-C]2

The rutie use f episit is t recommended during delivery. [leveI-D]2

Derivatives f pgcic acidappear t e the asrae ateriaf chice fr th deep ad skicsure. [leve I-A]2

Routine ‘active management’ is superiorto ‘expectant management’ in terms of blood loss, postpartum hemorrhage

and severe postpartum hemorrhageand other serious complications of thethird stage f ar. [leve I-A]2

Active management of labor includes:

1. Administration of a prophylacticoxytocin after delivery of the baby

2. Early cord clamping and cutting,and

3. Controlled cord traction of theumbilical cord 2

The use of the combination preparation(oxytocin and ergometrine) as partof the routine active management of the 3rd stage of labor appears to beassociated with a statistically signicantreduction in the risk of postpartumhemorrhage when compared tooxytocin when blood loss is less than1000mL. [leve I-D]2

PoSTPARTUm CARE

Pstpartu Visit

Postpartum follow up is recommended within 8 weeks after delivery. This

should cover family planning, to include various temporary contraceptive meansand/or permanent sterilization.2,4

Ear breastfeedig

Early breastfeeding is recommended for

all pregnant women after delivery.2,4

References (Search Date: September 2005)1. PhilHealth Health Technology Assessment

Committee. Proceedings of Workshop on the Critical Appraisal of Clinical Practice Guidelines and Development of Policy Statements. September 19-21, 2005

2. Philippine Board of Obstetrics and Gynecology. Clinical Practice Guidelines

DEfINITIoN

A There is good evidence to support

therecommendationofthepracticein

themanagementofnormallaborand

delivery

B Thereisfairevidencetosupportthe

recommendationofthepracticein

themanagementofnormallaborand

delivery

C Thereisinsufcientevidencetorecom-

mendfororagainsttheinclusionofthe

practiceinthemanagementofnormal

labor and delivery.

D Thereisfairevidencetosupportthe

recommendation that the practice be

excludedinthemanagementofnormal

labor and delivery.

E There is good evidence to support the

recommendation that the practice be

excludedinthemanagementofnormal

labor and delivery.

GRADE

TABLE25.GRADESofRECoMMENDATIoN(PBoG2002)

DiScLAiMEr

these eommendaons and esons wee based on avalable evdene and

may be modied based on the availability of new evidence. Furthermore, they

shold no eplae good, p-o-dae lnal jdgmen based on he pesen

msanes n eah ase.

All mednal pods menoned n he pol saemens have an nheen sk

prole and have to be used with prudence and caution in the clinical setting.

Dgs an ase nexpeed and nwaned advese dg effes and epong

hese evens o BFAD s eommended n lne wh pbl safe. the pesbe

shold ead he pod nfomaon aefll and help he paen ndesandthese risks in relation to the benets offered by these medicines. Drugs are safe

when sed n he pope wa.

We’d like to hear from you!For your comments and suggestions, you can e-mail us at

[email protected] or write us:

Healh tehnolog Assessmen commee

qal Assane reseah and Pol Developmen Gop12/F csae cene 709 Shaw Bolevad,

Pasg c 1600

www.phlhealh.gov.ph/a/ha.hm

DEfINITIoN

I Evidencefromatleast1properly

randomizedcontrolledtrial(RCT)

II-1 Evidencefromwell-designed

controlledtrialswithout

randomization

II-2 Evidenceobtainedfromwell-

designedcohortorcase-control

analyticstudies,preferablyfrom

morethanonecenterorresearch

group

II-3 Evidenceobtainedfrommultiple

timeserieswithorwithoutthe

intervention.Dramaticresultsin

uncontrolledexperimentscould

alsobeincludedhere

III Opinionsofrespectedauthorities,

basedonclinicalexperience;

descriptivestudiesandcase

reportsorreportsofexpert

committees

LEVEL

TABLE26.LEVELofRECoMMENDATIoN

(PBoG2002)

Documents

Hta Forum v4n1-2006