In respiratory acidosis, the plateau pressure should be in excess of 25 cm H2O and the ventilator rate should be increased. Dihydroartemsinin plus piperaquine (DHA+PPQ) has now been found to be as effective as other ACTs and therefore recommended for the treatment of uncomplicated falciparum malaria by the WHO. ACT known to be effective in the country/region or artesunate + clindamycin to be given for 7 days or quinine + clindamycin to be given for 7 days. The efficacy of hypertonic mannitol in treatment of cerebral edema is not proven. Patients with high parasite counts are known to be at increased risk of dying, although the relationship between parasite counts and prognosis varies at different levels of malaria endemicity. In a low-transmission area in north-west Thailand, the overall mortality of uncomplicated falciparum malaria was 0.1%, but in patients with parasitaemia of >4% it was 3%. Cardiac monitoring is not mandatory during treatment with artesunate, and no serious toxic effects due to the drug are anticipated.

The antimalarials considered safe in the first trimester of pregnancy are quinine, chloroquine, proguanil, pyrimethamine and sulfadoxine–pyrimethamine. [1] In hypotension early use of inotropic support is indicated rather than overhydration. DHA+PPQ is currently available as tablets of fixed-dose combination containing 40 mg of DHA and 320mg of PPQ. Amodiaquine + sulfadoxine-pyrimethamine may be considered as an interim option in situations where ACTs cannot be made available.[1]. Non-immune patients with parasitaemia of >20% should receive parenteral antimalarial treatment. Primaquine should be used in P. vivax and P. ovale malaria for eradicating the persisting liver forms and in P. falciparum malaria to destroy the gametocytes, so as to prevent the spread of infection. Bacterial infections can coexist with severe malaria, so blood cultures should be obtained from patients with shock or other signs of sepsis despite appropriate antimalarial therapy, and these patients should receive broad-spectrum antibiotic therapy. As P. knowlesi has no hypnozoites, primaquine is not necessary for its treatment. For the majority of patients with mild variants of the deficiency, primaquine should be given in a dose of 0.75 mg base/kg bw once a week for 8 weeks. There are no known interactions between artesunate and other drugs. If the patient has P. vivax, P ovale, P. malariae, or has been in an area where there is no chloroquine resistance in P. falciparum, chloroquine is the best drug to use to treat malaria. [1] Data on children in high-transmission regions are limited, and the WHO recommends treatment with artesunate, artemether, or quinine. In South Africa, treatment is usually with either an artemesinin derivative called artemether in combination with lumefantrine (Coartem), or with quinine combined with doxycycline.

[8], The dosage of artemisinin derivatives does not need adjustment in vital organ dysfunction. Prompt and effective treatment and case management should be the same as for severe and complicated falciparum malaria. Mefloquine has important neuropsychiatric and cardiac adverse effects; not an ideal drug for pregnancy[9]; cannot be used concomitantly with quinine or quinidine. Do you suffer from 'text neck' when using your cell phone? [8] The Cochrane review on the Artemisinin derivatives for treating severe malaria concluded that the artemisinin drugs are no worse than quinine in preventing death in severe or complicated malaria and that no artemisinin derivative appears to be better than the others. In epidemic situations, staff shortages and high workloads make intensive care monitoring difficult. See additional information. Management of severe malaria comprises four main areas: clinical assessment of the patient, specific antimalarial treatment (regimen, follow-on treatment, pre-referral treatment, artimisinin, quinine/quinidine), adjunctive therapy and supportive care.[1]. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.

These general recommendations still need to be tailored to the individual, as the pathological consequences of rapid development of anaemia are worse than those of acute on chronic anaemia, where there has been adaptation and a compensatory right shift in the oxygen dissociation curve. Malaria is probably the only disease of its kind that can be easily treated in just 3 days, yet if the diagnosis and proper treatment are delayed, it can kill the patient very quickly and easily. The role of early Caesarean section for the viable live fetus is unproven, but is recommended by many authorities.

2nd edn. Regimens containing mefloquine should be avoided if the patient presented initially with impaired consciousness. cdc.gov/malaria/resources/pdf/treatmenttable.pdf, http://www.tm.mahidol.ac.th/seameo/2010-41-1/03-4750.pdf, http://apps.who.int/iris/bitstream/10665/144852/2/9789241564830_eng.pdf, http://content.nejm.org/cgi/content/full/358/17/1829, http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000527/frame.html, http://apps.who.int/iris/bitstream/10665/79317/1/9789241548526_eng.pdf, Symptoms are caused by blood forms of the parasite, Chloroquine, quinine, artemisinin combinations, Chloroquine 25 mg of salt/kg over 36-48 hours, Primaquine 0.75mg/kg in single dose as gametocytocidal, If the patient comes in the morning and treatment can be started by mid-day, If the patient comes in the afternoon and treatment is started by evening, If the patient is coming from a far off place and /or if the MP test report is available only next day. The risk of death from severe malaria is greatest in the first 24 h, yet in most malaria endemic countries, the transit time between referral and arrival at appropriate health facilities is usually prolonged thus delaying the commencement of appropriate antimalarial treatment, during which time the patient may deteriorate or die. These species are also susceptible to amodiaquine, mefloquine and the artemisinin derivatives.
Patients with P. falciparum malaria should be evaluated thoroughly in view of potential seriousness of the disease and possibility of resistance to anti malarial drugs. Thus, in effect, a blood schizonticidal drug and Primaquine should be administered to ALL types of malaria. Unconscious patients should have a lumbar puncture for cerebrospinal fluid analysis to exclude bacterial meningitis.

The WHO recommends artesunate or quinine during the first trimester and artesunate as the first-line therapy during the second and third trimesters. From a public health perspective, treatment is meant to reduce transmission of the … The most common toxic effects that have been identified are nausea, vomiting, anorexia, and dizziness; these are probably due, in many patients, to acute malaria rather than to the drugs.
2000;(2): CD000527.

Under the NVBDCP, Artesunate + Sulfadoxine–pyrimethamine kits are available for free at all the PHCs. Where available, clindamycin may be substituted in children and pregnant women, as doxycycline cannot be given to these groups. Antimalarial drugs used in severe malaria: Artemisinin Derivatives: Artemisinins, the most important new class of antimalarial agents, have the key advantage of rapid action against all of the erythrocytic stages of the parasite, including transmissible gametocytes, resulting in a rapid clinical benefit and decreased transmission of malaria. It can be used for uncomplicated malaria if the patient is able to take medication orally. Blood glucose should be checked, using rapid stick tests every 4 h if possible, particularly in unconscious patients. The underlying mechanisms of severe manifestations are not well understood. [1], Recommended by WHO for children in high transmission areas; regimen 1 can also be used. Severity of infection: All patients with malaria should be carefully and thoroughly assessed for complications of malaria. Quinine was the first drug used to successfully treat malaria, and with increasing chloroquine resistance, it is making something of a “comeback”. This is dissolved in sodium bicarbonate (5%) to form sodium artesunate. Comments have been closed for this article. The artemether/lumefantrine combination has been used since 2001 in Kwazulu Natal with good results. The efficacy of intramuscular artemether in severe malaria may be limited by varied absorption of this fat-soluble artemisinin derivative. Parenteral Chloroquine: Parenteral chloroquine (rarely needed these days) may be needed in patients with drug sensitive malaria with persistent vomiting. Fat-containing food (like milk or butter) enhances the absorption of this ACT and is therefore recommended, particularly on the second and third days of treatment. For chloroquine-resistant vivax malaria, Amodiaquine (30 mg base/kg bw divided over 3 days as 10 mg/kg bw single daily doses) combined with primaquine should be given. Geneva, 2012. Parenteral anti malarials are needed only in cases of severe malaria or uncontrolled vomiting. [1], Various adjunctive treatments for the complications of malaria may be needed to reduce the unacceptably high mortality of severe malaria. Doses used have been variable and empiric: 10–40 mg/kg bw (at 0, 4 or 12, 24, 48 and 72 h). Many hyperparasitaemic patients have evidence of vital organ dysfunction but there is a large subgroup in which no other manifestations of severe disease are present. Atovaquone–proguanil (15/6 mg/kg; usual adult dose, 4 tablets once a day for 3 days), Artemether–lumefantrine (adult dose, 4 tablets twice a day for 3 days), Quinine (10 mg salt/kg bw every 8 h) + doxycycline (3.5 mg/kg bw once a day) or clindamycin (10 mg/kg bw twice a day); all drugs to be given for 7 days, Artesunate plus Sulfadoxine-pyrimethamine, Artesunate plus clindamycin or doxycycline, Recommended by WHO in low transmission areas or outside malaria endemic areas. Care should be taken to ensure that the water is not too cool as, paradoxically, this may raise the core temperature by inducing cutaneous vasoconstriction. [7] Dosage adjustment by one-third is necessary in patients with hepatic dysfunction. Management of Severe Malaria: A practical handbook. Neurotoxicity is the greatest concern regarding artemisinins, since the administration of high doses in laboratory animals has led to severe and irreversible changes in the brain. The optimum duration of treatment for hyperparasitaemia is still unresolved. Negative fluid balance is critical to avoid exacerbating acute lung injury, but is balanced against the risk for precipitating acute renal failure[7], Early institution of renal replacement therapy may avoid the development of ARDS. [7] National Vector Borne Disease Control Programe in India recommends quinine as the treatment for severe malaria in pregnancy. How do physicians diagnose malaria? However, artesunate + sulfadoxine-pyrimethamine may not be effective against P. vivax in many areas owing to the resistance to pyrimethamine.