Malaria Clin&Manag S1

8/10/2019 Malaria Clin&Manag S1

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Malaria

Malaria is a protozoan disease transmitted by the bite ofinfectedAnophelesmosquitoes.

Most important of the parasitic diseases of humans, withtransmission in 103 countries affecting more than 1 billionpeople and causing between 1 and 3 million deaths each year

Four (or 5 ?) species of the genus Plasmodiumcause nearlyall malarial infections in humans : P. falciparum, P. vivax, P.ovale, and P. malariae(the 5th is P. knowlesi)

Almost all deaths are caused by falciparum malaria.


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CLINICAL FEATURES Clinical symptoms include the following: Fatigue,

Malaise, Shaking chills, Arthralgia, Myalgia, Paroxysm offever, shaking chills, and sweats

The classic paroxysm begins with a period of shiveringand chills, which lasts for approximately 1-2 hours, andis followed by a high fever. Finally, the patientexperiences excessive diaphoresis, and the bodytemperature of the patient drops to normal or belownormal

Less common symptoms include the following:

Anorexia and lethargy Nausea and vomiting

Diarrhea

Headache


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Laboratory examination Giemsa-stained thick and thin peripheral blood smears

These smears are the criterion standard for malaria

detection and should be sent to the laboratory

immediately, since malaria is a potentially life-

threatening infection.

When reading the smear, 200-300 oil-immersion

fields should be examined (more if the patient

recently has taken prophylactic medication, because

this temporarily may decrease parasitemia). Rapid diagnosis test

PF test, ICT test, paracheck, OptiMAL


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Manifestations of Severe Falciparum MalariaSigns Manifestations

Unarousable coma/cerebral malaria Failure to localize or respond appropriately to noxious stimuli; coma persisting for >30 min after

generalized convulsion

Acidemia/acidosis Arterial pH


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Differential Diagnosis

Typhoid fever

Dengue Fever URTI

Leptospirosis


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ALGORITME MALARIA CASE MANAGEMENT

No Rapid Test &

No Microsc

Microscopic Exam

No evidence:

URTITYPHOID

UTI

DENGUE

Leptospirosis

Other Infection

FalciparumMixed/F+VVivax

SEVEREMILD /

MODERATE Parasite ++++/>5% or

/+complications ;

Cerebral

Icteric, Bil > 3mg%

Systolic 35

Oliguria+Creat> 3 mg%

Rapid Test ( Yes) &

No Microscopic

Step. I: CQ3+PQ1SEVEREMalaria

Treatment

Rapid Test + Rapid Test -

Microscopic Confirmation

Step. I: CQ3+PQ1

Step. I: CQ3+PQ1

STEP. I: CQ3+PQ14

Step. II: QN7+PQ1

Step. II: SP1+PQ1

Step. III: QN7+PQ1

No evidence:

URTI

TYPHOID

UTI

DENGUE

Leptospirosis

Other Infection

Step. II: QN7+PQ14

Step. III: CQ1+PQ1/ week


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Management of Severe Malaria


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Initial management of Severe Malaria

Clear & maintain airway

Position semiprone or on side

Weight patient, calculate dosage

Start antimalarial chemotherapy

Make rapid clinical assesment Exclude or treat hypoglycaemia

Asses state of dehydration

Measure & monitor urine output, if nes. Catheter, S.G

Diagnostic smear, rapid test, other lab test

Plan first 8 hrs i.v. fluid, including anti malarial, glucose, bloodtrasfussion

Consider CVP line

If temp. rectal > 39 C, r. clothes, tepid sp., fan, cooling

Lumbal puncture, to exclude meningitis

Anti convulsant, anti-microbials, vit.K


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SPECIFIC TREATMENT SEVERE

MALARIA ( Anti Malaria)

PARENTERAL

START IMMEDIATELY

DOSAGE, WEIGHT THE PATIENT

MONITORING RESPONSE

SWITCHED TO ORAL WHEN POSSIBLE

MONITORING SIDE EFFECTS


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ANTI MALARIAL THERAPY FOR S.M

QUININE

QUINIDINE

CHLOROQUINEARTEMISININ :

ARTESUNATE : I.V/ I.M / SUPPOSITORIES

ARTEMETHER : I.M

ARTEMISININ SUPP


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RECOMMENDED DOSES OF ANTI MALARIAL

DRUGS FOR TREATMENT OF

SEVERE/CEREBRAL MALARIA

Hypoglycemia, chinchonism,

tinnitus, hearing

impairment, nausea,dysphoria, vomiting,

prolonged QT interval,

dysrhythmias,

hypotension

20 mg of dihydrochloride salt/kg by iv

infusion over 4 hr, then after

loading, followed by 10 mg/kg over4 hr every 8 hr. Patients should not

received quinine or mefloquine

within last 24 hr

Alternatively, 7 mg of salt/kg can be

infused over a period of 30 min,

followed by 10 mg salt/kg over a

period of 4 hr, or

10 mg of salt/kg (500 mg for adult) by

i.v infusion over 8 hr continously 3 x

a day

Quinine

DRUGS SIDE EFFECTS


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RECOMMENDED DOSES OF ANTI MALARIAL

DRUGS FOR TREATMENT OF

SEVERE/CEREBRAL MALARIA

Hypotension

3.2 mg/kg im initially, followed by1.6 mg/kg daily. Not to be

given iv (1 amp = 80 mg)Suppositories, 10 mg/kg at 0 & 4hr followed by 7 mg/kg at24,36,48 & 60 hrs.

10 mg base/kg infusion atconstant rate over 8 hrs

followed by 15 mg/kg over 24hrs, or

3.5 mg base/kg 6 hourly or 2.5 mgbase/kg 4 hourly by im or scinjection. Total dose 25 mgbase /kg

Artemeter

DRUGS SIDE EFFECTS

Artemisinin

Chloroquine


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Artesunate

2,4 mg/Kg/ with 3-5 ml 5% Dekstrose, IV in 2

minutes. Repeat in 12 hours. Then every 24 hours with same dose

Oral Preparations after the patient can eat

and drink well


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Convulsions

I.v. diazepam 10 mgadult or rectal 0.5-1.0

mg/kg i.m paraldehyde o.1 mg/kgadult

Repeated conv- chlormethiazol infussion 0.8 %,

Phenytoin 5 mg/kg i.v. 20 minutes

Fosphenytoin 7.5 mg/kg i.v 20 mnutes


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HYPOGLYCAEMIA ( Bl. Sugar < 40 mg% )

Coma, 20 -50 ml 50% dextrose i.v. 510 minutes (

routine is not recommended )

Infussion 10 % dextrose ( children5% dextrose)

beware hyponatremia

Hypoglycaemia may developed Day 1 --- 7

Pushed 50% dextrose if necessary

Via nasogastric , beware gastric distension In peritoneal dialysis, add glucose in dialysis fluid

Prophylaxis and Self Treatment for Malaria


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Prophylaxis and Self-Treatment for MalariaDrug Prophylaxis Usage Adult Dosage Child Dosage

Mefloquine Used in areas where chloroquine-resistant malaria has

been reported

228 mg of base (250 mg of salt) orally,

once/weeka

45 kg: 1 tablet/week

Doxycyclineb Used as alternative to mefloquine 100 mg orally, once/day >8 years of age: 2 mg/kg per day orally;

maximum dose, 100 mg/d

Chloroquine Used in areas where chloroquine-resistant malaria has

notbeen reported

300 mg of base (500 mg of salt) orally,

once/week

5 mg of base/kg (8.3 mg of salt/kg) orally,

once/week; maximum dose, 300

mg of base

Proguanil (not available

in U.S.)

Used simultaneouslywithchloroquine as alternative to

mefloquine or doxycycline

200 mg orally, once/day, in

combination with weekly

chloroquine

10 years: 200 mg/d

Primaquinec Used for travelers only after testing for G6PD

deficiency; postexposure prevention for

relapsing malaria or prophylaxis

Postexposure: 15 mg of base (26.3 mg

of salt) orally, once/day for 14

days

Prophylaxis: 30 mg of base daily

0.3 mg of base/kg (0.5 mg of salt/kg)

orally, once/day for 14 days

Atovaquone-proguanilc Used as alternative to mefloquine 250/100 mg orally once/day 11-20 kg 62.5 mg/100 mg

21-30 kg 125 mg/50 mg

31-40 kg 187.5 mg/75 mg

>40 kg 250 mg/100 mg

Self-treatment

Pyrimethamine-

sulfadoxined

In areas with chloroquine-resistant malaria, should be

carried during travel by persons taking

mefloquine or doxycycline

3 tablets (75 mg of pyrimethamine and

1500 mg of sulfadoxine) orally,

as a single dose

5-10 kg: 1/2tablet

11-20 kg: 1 tablet

21-30 kg: 1 1/2tablets

31-45 kg: 2 tablets

>45 kg: 3 tablets

aTablets manufactured outside the United States contain 250 mg of base.

bNot in pregnant women or children


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Malaria Clin&Manag S1