HOW TO MANAGE MALARIA IN A OUT-

PATIENT CLINIC IN ETHIOPIA

Dr. Dino SgarabottoMalattie Infettive e Tropicali

Azienda Ospedaliera di Padova

MALARIA• The most serious and life-threatening disease occurs

from Plasmodium Falciparum infection, which usually presents with acute fever, chills, sweating and headache

• It can progress to jaundice, coagulation defects, shock, renal and liver failure, acute encephalopathy, pulmonary and/or cerebral edema, coma and death.

• Prompt diagnosis and treatment is essential even in mild cases to prevent complications.

Other species• Plasmodium vivax (benign tertian),

Plasmodium malariae (quartan) and Plasmodium ovale, are not life-threatening, except in:– the very young, – very old,– immuno-deficient cases

Standard Diagnosis• Smear microscopy remains the most

important diagnostic tool:– Thick and thin blood film stained with MGG

It is also helpful to estimate the degree of parasitemia, which is extremely useful not only to predict severity but also response to treatment as well.

Plasmodium falciparum Plasmodium vivax

Thin blood film x100

Thick blood film x100

New diagnostic kits• Similar to urine pregnancy test, but the

malaria diagnostic kits are performed from 1-2 drops of blood

Positive

Uncomplicated P. falciparum malaria

• First line treatment• Artemether + Lumefantrine, 80 + 480mg P.O.

BID for 3 days• S/Es: nausea, vomiting, diarrhea• C/Is: first trimester pregnancy• Dosage forms: Tablet, 20mg +120mg• Total number of tablets: 24 (Coartem 4 Tabs

BID for 3/7)

Uncomplicated P. falciparum malaria

• Alternative treatment• Quinine sulphate, 600 mg TID for 7 days.• S/Es: Cinchonism, including tinnitus, headache, nausea,

abdominal pain, rashes, visual disturbances, confusion, blood disorders (including thrombocytopenia and intra-vascular coagulation), and acute renal failure.

• C/Is: Hemoglobinuria, optic neuritis• Dosage forms: Tablet 300mg and 600mg;

injection, 300mg/ml in 1 ml ampoule.

Pediatric DosingBody Weight Artemether/Lumefantrine (CoartemTM) Pediatric Dosing

5 kg to < 15 kg 1 tablet at hour 0 and at hour 8 on the first day, then 1 tablet twice daily (in the morning and evening) on days 2 and 3 (total of 6 tablets per treatment course)

15 kg to < 25 kg 2 tablets at hour 0 and at hour 8 on the first day, then 2 tablets twice daily (in the morning and evening) on days 2 and 3 (total of 12 tablets per treatment course)

25 kg to < 35 kg 3 tablets at hour 0 and at hour 8 on the first day, then 3 tablets twice daily (in the morning and evening) on day 2 and 3 (total of 18 tablets per treatment course)

≥35 kg (adult dosing) 4 tablets at hour 0 and at hour 8 on the first day, then 4 tablets twice daily (in the morning and evening) on days 2 and 3 (total of 24 tablets per treatment course

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.

– 1. If necessary insert urethral catheter.– 2. Measure urine specific gravity.

• Take blood for diagnostic smear, monitoring of blood sugar ('stix' method), haematocrit and other laboratory tests.

• Plan first 8 hrs 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 at 10 mg / kg and it should be given 8 hourly diluted in 500 ml of isotonic saline or 5 % dextrose over 4 hours.

• The parenteral treatment should be changed to P.O. as soon as the patient‘s condition improves and if there is no vomiting. Oral treatment should be given with Artemether + Lumefantrine in the doses as indicated above. However, if a patient has a history of intake of Artemether + Lumefantrine before complications developed, give Quinine tablets 10 mg salt per kg TID tocomplete 7 days treatment.

Severe and complicated P. falciparum malaria

P. vivax malaria• Chloroquine phosphate, 1 g, then 500 mg

in 6 hours followed by 500 mg QD for 2 days, i.e.: Chloroquine 250 mg 4 Tabs stats, then 2 tabs after 6 hours, then 2 tabs OD for 2/7 (totale 10 Tabs)

• or 1 g at 0 and 24 hrs followed by 0.5 g at 48 hrs P.O, i.e.: Chloroquine 250 mg 4 Tabs stats, then 2 tabs OD for 2/7 (totale 8 Tabs)

• Pruritus is not uncommon in persons with darker skin pigmentation.

In P. vivax malaria• Chloroquine should be followed by

Primaquine, 15mg base P.O. 1 Tab OD for 14 days.• S/Es: Nausea, vomiting anorexia, and less

commonly hemolytic anemia, especially in patients with G6PD deficiency.

• P/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

THANK YOU!

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