Malaria is a parasitic infection. There are four main species known to affect humans. The most serious and life-threatening disease occurs from Plasmodium Falciparum infection, which usually presents with acute fever, chills, sweating and headache progressing to icterus, coagulation defects, shock, renal and liver failure, acute encephalopathy, pulmonary and cerebral edema, coma and death. It is a possible cause of coma and other CNS symptoms in any person who has recently traveled to malarius areas. Prompt treatment is essential even in mild cases. The other species, Plasmodium vivax (benign tertian), Plasmodium malarea (quartan) and Plasmodium ovale, are not life-threatening, except in the very young, very old and immuno-deficeint cases.
Diagnosis can be confirmed by demonstration of malaria parasites in the blood film. Often, repeated microscopic examinations may be necessary. It is also helpful to estimate the degree of parasitemia, which is extremely useful not only to predicate severity but gauge response to treatment as well.
I. Treatment
A. P. Falciparum
i. Uncomplicated P. Falciparum malaria
First line:
Chloroquine sensitive:
Chloroquine phosphate, 25 mg base/kg over 3 days p.o. (4 tablets p.o. stat, followed by 2 tablets after 8 hours, then 2 tablets per day for two consecutive days.).
Children: 10 mg/kg initially, then 5 mg/kg 6, 24 and 48 hrs after the first dose.
S/E: dizziness, GI discomfort and pruritus.
C/I: alcoholism, history of hypersensitivity, epilepsy and psoriasis.
D/I: antacids reduce absorption and cimetidine reduces metabolism.
Dosage forms: tablet, 150 mg base; syrup 50 mg base/5ml.Injection, 150 mg base in 5 ml ampoule.
Alternative:
Sulfadoxine 500 mg + pyrimethamine 25 mg
• 3 tablets orally once. If parentral preparation is required, 2 ampoules of the injectable form (e.g. Fansidar) can be given IM or IV slowly.
Note: The total 24 hours dose should not exceed 2000mg.Oral therapy should be started as soon as the patient regains consciousness.
• Children’s dose: depends on age:
a. Less than 3 years: ½ tablet (250 mg Sulfadoxine + 25 mg Pyrimethamine
b. 4-11 years: 1 tablet = (500 mg Sulfadoxine + 25 mg Pyrimethamine)
c. 12-15 years: 2 tablets = (1000 mg Sulfadoxine + 50 mg Pyrimethamine
Parentral Sulfadoxine 500 mg + pyrimethamine 25 mg is given as follows:
Depends on age:
a. 0-4 years: 0.5-1.5 ml (1/4ampoule).
b. 5-8 years: 1.5-2 ml (3/4-1 ampoule)
c. 9-14 years: 2-3 ml (1-1 ½ ampoule)
S/I: Depression of hematopoiosis with high doses, rashes and insomnia.
Caution: Hepatic or renal impairment, folate supplement in pregnancy, breast feeding, blood counts required in prolonged use, infants less than 2 months, hepatic or renal dysfunction.
Dosage forms: tablet, sulfadoxine (500 mg) + pyrimethamine (25 mg); injection, sulfadoxine (500 mg) + pyrimethamine (25 mg) in 2.5 ml ampoule
Quinine dihydrochloride,600 mg (2 tablets) can be given 8 hourly for 7 days if Sulfadoxine + pyrimethamine fails.
S/E: Cinchonism, including tinnitus, headache, nausea, abdominal pain, rashes, visual disturbances, confusion, blood disorders (including thrombocytopenia and intra-vascular coagulation), and acute renal failure.
C/I: Hemoglobinuria, optic neuritis
Dosage forms: tablet (dihydrochloride or sulphate), 300mg, and 600mg; injection, 300mg/ml in 1 ml ampoule.
ii. Severe and complicated P. falciparum malaria
Non-Drug treatment:
• Clear and maintain the airway.
• Position semi-prone or on side.
• Weigh the patient and calculate dosage.
• Make rapid clinical assessment.
- Exclude or treat hypoglycemia (more so in pregnant women).
- Assess state of hydration.
• Measure and monitor urine output.
- If necessary insert urethral catheter.
- Measure urine specific gravity.
• Take blood for diagnostic smear, monitoring of blood sugar ('stix' method), haematocrit and other laboratory tests.
• Plan first 8 h of intravenous fluids including diluents for anti-malarial drug, glucose therapy and blood transfusion.
• If rectal temperature exceeds 39°C, remove patient's clothes, use tepid sponge,
• Lumbar puncture to exclude meningitis or cover with appropriate antibiotic.
• Consider other infections.
• Consider need for anti-convulsant treatment
Drug Treatment
Quinine dihydrochloride:
Loading dose: 20 mg/kg in 500 ml of isotonic saline or 5 % dextrose over 4 hours (4 ml/minute). The pediatric dose is the same but the fluid replacement must be based on body weight.
Maintenance dose: should be given 8 hours after the loading dose of 10 mg/kg to be give 8 hourly diluted in 500 ml of isotonic saline or 5 % dextrose over 4 hours. The parentral treatment should be changed to p.o. as soon as the patient condition improves and if there is no vomiting. Treatment should be given for an average of seven days.. (For S/E and Dosage foms, see page 15)
PLUS
Doxycycline, 200 mg p.o. four times daily for 7 days
S/E: nausea, vomiting, hepato-toxiciy, hypersensitivity reactions.
C/I: renal impairment, pregnancy and breast-feeding.
Dosage forms: Capsule,100 mg;.tablet,100mg.
N.B.
If there is no improvement in the patient's condiction, refer to the nearby district hospital.
P. Vivax
Chloroquine phosphate, 1 g, then 500 mg in 6 hours followed by 500 mg daily for 2 days, or 1 g at 0 and 24 hrs followed by 0.5 g at 48 hrs p.o
(For S/E, C/I and dosage forms, see page 14)
Followed by
Primaquine, 15mg base as a single dose daily for 14 days p.o.
S/E: Nausea, vomiting anorexia, and less commonly hemolytic anemia, especially in patients with G-6-P-D deficiency.
Caution: In patients with G6PD deficiency; systemic diseases associated with granulocytopenia, e,g. rheumatoid arthritis, and pregnancy and breast feeding)
Dosage forms: Tablet, 7.5mg base, 15mg base
II. Chemo-prophylaxis
P. Falciparum
Chloroquine sensitive:
First Line
Chloroquine phosphate, 300 mg (as base) p.o. weekly:
For Children, Chloroquine 5mg/kg p.o weekly.
Length of Prophylaxis: Preferably taken 1 week before travel and until 4 weeks after return.
(For S/E, C/I and dosage forms, see page 14)
Chloroquine resistant: Refer to nearby Health center
