Transcript MALARIA TREATMENT PROTOCOL

MALARIA TREATMENT PROTOCOL
Third edition
June 2007
Ministry of Health
Republic Democratic of Timor- Leste
UNCOMPLICATED MALARIA

Uncomplicated malaria definition:
Fever and any of the following:
 Headache,
 Body and joint pains
 Feeling cold and sometimes shivering
 Loss of appetite and sometimes abdominal pains
 Diarrhoea, nausea and vomiting.
 Spleenomegaly
Confirmed Diagnosis of Malaria
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All clinically suspected malaria cases require
laboratory examination and confirmation.
Only in case where laboratory confirmation is
not possible start treatment immediately.
Parasitological confirmation is done by thinthick blood smear microscopy examination or
by dipstick (Rapid Diagnostic Test [RDT]).
Differential diagnosis for
uncomplicated malaria
Consider other illnesses, such as:
 Upper respiratory tract infection
(Pharyngitis, tonsillitis, ear infection),
pneumonia , measles, dengue, influenza,
typhoid fever.
Remember that the patient may be suffering
from more than one illness.
Uncomplicated malaria treatment
P. falciparum malaria
 The treatment of uncomplicated P. falciparum
malaria is undertaken after diagnosis of
malaria by light microscopy or Dipstick.
 Patients with positive think-thick blood
smears or dipstick for P. falciparum malaria is
treated by blisters of Coartem® (artemether
20mg/lumefantrine 120mg). See Table 1 for
details of prescription.
Table 1 : Dosage and administration Coartem (Artemether 20
mg/Lumefantrine 120 mg) for uncomplicated
malaria falciparum
Age group
4 months
to 5yrs
6 to 11y
12 to 14y
> 14y
Weight group
5 to 14 kg
15 to 24 kg
25 to 34 kg
> 34
Blister
color
Yellow
Blue
Orange
Green
Source: Guideline for the treatment of malaria, WHO; 2006
(Day 1)
(Day 2)
(Day 3)
1 tb R,
1 tb R,
1 tb R,
1 tb Z
1 tb Z
1 tb Z
2 tb R,
2 tb R,
2 tb R,
2 tb Z
2 tb Z
2 tb Z
3 tb R,
3 tb R,
3 tb R,
3 tb Z
3 tb Z
3 tb Z
4 tb R,
4 tb R,
4 tb R,
4 tb Z
4 tb Z
4 tb Z
Coartem® Dosage Schedule
Source: WHO, 2007
Important notes (1)
1. It is obligatory to give Coartem® to patient whose
dipstick test or blood slide is positive for P.
falciparum and to the patient who has mixed
infections P. falciparum and P .vivax.
2. Give the correct dosage of Coartem® from the
appropriate blister according to the patient’s weight
or age.
3. Children under 5 kg or below 4 months should not
be given Coartem instead treat with the following
regimen (see table 2).
Table 2. Dosage and administration Plasmodium
falciparum for young infant
Age Group
0-4
months
Weight
group
<5 kg
Artesunate
** IM first dose
Artesunate 1.2
mg/kg or IM
Arthemeter 1.6
mg/kg)
***Oral
Artesunate
2mg/kg/day
day 2 to day 7
or *Quinine
Oral
Quinine 10
mg/TID for
4 days
then 15-20
mg/kg TID
for 4 days
Source: Malaria in Children, Department of tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University.
** Preferably Artesunate/Artemether IM on day 1 if available
*** When Artesunate/Artemether IM is unavailable, give oral Artesunate from day 1 to day 7
* Treat the young infant with Quinine when oral Artesunate is not available
Important notes (2)
4.
5.
In case parasitological diagnostic facilities are not available
paracetamol could be given to relieve pain and fever and
referred to health facilities where parasitological diagnosis
will be carried out.
Only in exceptional case when there is problem with the
referring patient in other health facility coartem® could
be administered. (The health facility manager should
write explanatory note why giving coartem® without
parasitological diagnosis).
Important notes (3)
6. Watch all patients swallowing the first dose of
coartem® and observe for 1 hour after the intake. In
the event of vomiting within one hour of
administration, a repeat dose should be taken.
7. Inform patient that, the coartem® tablets are in the
blister and after breaking should be taken
immediately, as after 24 hours coartem® tablets
exposed to air totally inactivated and can not be
used for treatment of malaria.
8. Each blister of coartem® has expiry date and should
not be used after the expiry date.
Important notes (4)
9. For small children, paracetamol and coartem®
can be crushed, diluted in water and then put
either directly into the mouth using a syringe
or given with a spoon.
10. Any patient who seeks re-treatment for
malaria within 2 weeks of taking full dose of
any other antimalarial should be treated with
coartem®.
Uncomplicated malaria treatment
P. vivax malaria
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•
Resistance of P. vivax to chloroquine has not been found
in Timor-Leste and Chloroquine is the drug of choice
Chloroquine is safe and has few side effects.
For the radical treatment of P. vivax in addition to
chloroquine, primaquine is recommended 0.5mg/kg per day
for 14 days (primaquine should always be taken with food).
Chloroquine can be given to pregnant women and
children.
Primaquine is not recommended for the children under
one year and pregnant women.
Details of treatment see table 4a.
Table 4a. Dosage and administration of Chloroquine and
Primaquine for malaria vivax.
Age Group
* Weight
group (Kg)
CHLOROQUINE
(150 mg base) 10 mg/kg on the
first two days.
5 mg/kg on day 3
Give for 3 days
PRIMAQUINE
(15 mg base)
0.5 mg/kg bw
Day 1
Day 2
Day 3
Start concurrently with CQ
and give daily for 14 days
4 months up
to 12 months
4 - <10
½
½
¼
-
13 months up
to 5 years
10 - <19
1
1
½
¼
6 - 7 years
19 - < 24
1½
1½
1
½
8 - 11 years
24 - <35
2½
2½
1
¾
12 - 14 years
35 - < 50
3
3
2
1½
15 +
50 or more
4
4
2
2
P. vivax malaria

Young infant less than 5kg or below 4
months should be treated with Chloroquine
alone for three days consecutive (Table 4b).
Table 4b. Dosage and administration of Chloroquine
for malaria vivax in young infant
Chloroquine
Age
Group
0-4
months
Weight
group
<5 kg
Day 1
Day 2
Day 3
10 mg/kg
5 mg/kg
5 mg/kg
P. falciparum and P. vivax
(mixed infections)
The type of malaria where both infections
occurs in patient requires treatment by
Coartem®.
Notes:
Negative dipstick or thin-thick blood smear:
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If the Pf dipstick is negative and the clinical signs are typical for
malaria, treat with Chloroquine (it could be a case of P. vivax
infection).
If the Pf dipstick is negative and the clinical signs don’t suggest malaria,
do not treat like malaria; look for another illness.
If the blood slide is negative, look for another illness.
If symptoms persist, ask for another dipstick or blood slide.
If dipstick and/or thin-thick blood smear are not available:
If there is no possibility of dipstick or slide results, treat the patient based
on the clinical signs and symptoms. Treat as if the patient has P.
falciparum.
Follow-up of uncomplicated
malaria:
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If symptoms persist after treatment with coartem® or if
the patient comes back before the 14th day after treatment.
Treatment failure within 14 days of receiving coartem® is
extremely rare and is more likely to be an inadequate
absorption of the drug(s) than resistance of the parasites. It
is important to determine from the patient’s history whether
he or she vomited during the previous treatment or did not
complete the full course.
If patient is in health facility where microscope is
available failure of treatment should be confirmed
parasitologically and could be treated using the following
regimen:
Follow-up of uncomplicated
malaria:
For adult:

Quinine (10mg salt /kg bw three times a day) + doxycycline (3.0mg/kg
bw once a day) for 7 days. Do not give doxycycline with milk or iron,
which will reduce its absorption.

If patient is in health facility where microscopy facility is not available
patient should be referred to the facility where microscope is
available. If refer is not possible treatment should be given Quinine +
Doxycycline. Please refer to Table 5 for details of the prescription.

Doxycycline should not be given to pregnant or lactating woman, or
child aged up to 8 years.
For pregnant or lactated woman or child less than 8 years:
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Quinine (10mg salt /kg bw three times a day) + clindamycin (10mg/kg
bw twice a day) for 7days. For small children, (quinine and
clindamycin) crush tablets and mix with water and sugar.
Note:
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For high transmission areas where
parasitological confirmation is not
available, children <5 yrs of age is
recommended to be treated with anti
malarial drugs when symptomatic
(especially fever).
SEVERE MALARIA
Severe or complicated malaria definition:
Fever and any of the following:

Impaired consciousness
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Anxiety, palpitation and sweating
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Convulsions or fits with this fever
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Fast or difficult breathing
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Vomiting every feed / unable to feed
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Pale hands, tongue and inner parts of the eyelid
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Generalized body weakness
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Dehydration
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Jaundice
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Severe malnutrition
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Dark urine or no urine
Pre-referral treatment of severe
malaria
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A patient who is non responsive should be quickly assessed
and managed. This includes assessment of the airway,
breathing and circulation. The staff at the first level health
facility should be able to maintain airway, provide assisted
breathing and manage shock if required.
Pre-referral treatment for severe malaria the administration
of Artesunate by the rectal route is recommended for all
except pregnant women first trimester pregnancy. For the
complete dosage and treatment.
Check blood sugar, if possible!
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In case Artesunate suppository is not available
IM quinine injection 20mg/kg bw should be
given. The Quinine injection dosage should be
split and injections given in the anterior part
of the thigh.
In case Artesunate suppository is not
available, give also Quinine for children
with severe malaria.
Confirmed diagnosis of severe
malaria:


All clinically suspected severe malaria cases
require laboratory examination and
confirmation.
Only in case where laboratory confirmation
is not possible start treatment immediately.
Parasitological confirmation is done by thinthick blood smear microscopy examination
or by dipstick (Rapid Diagnostic Test
[RDT]).
Differential diagnosis for complicated
malaria


Consider other illnesses, such as:
Measles, meningitis, tonsillitis, dengue,
otitis media (ear infection), influenza,
pneumonia, typhoid fever, tuberculosis,
hypoglycemia.
Specific severe malaria treatment

Artesunate (60 mg): 2.4 mg/kg body weight (bw)
IV or IM on admission (time=0), followed by 2.4
mg/kg at 12 and 24 hours, followed by once daily for
seven days. Once the patient can tolerate oral
therapy, treatment should be switched to a complete
dosage of coartem® for three days as recommended
in the national treatment guidelines for
uncomplicated malaria .
The congenital malaria is also treated with
Artesunate, where 2.4 mg/kg is initially given
through IV, followed by 1.2 mg/kg at 12 and 24 hr
then every 24 hr for 3 -5 days.
Specific severe malaria treatment
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Artemether (80mg for adult and 40 mg for children
and the newborn): 3.2 mg/kg bw IM on the first day
followed by 1.6 mg/kg bw daily for seven days.
Once the patient can tolerate oral therapy, treatment
should be switched to a complete dosage of
coartem®.
Arteether (150 mg): 3.2 mg/kg bw IM on the first
day, followed by 1.6 mg/kg bw for the next 4 days.
Once the patient can tolerate oral therapy, may
switch to a complete dosage of coartem®.

If Coartem® is not available, quinine
should be administered in combination
with tetracycline or doxycycline or
clindamycin, to complete the seven-day
treatment, except for pregnant women and
children under eight years of age for whom
tetracycline/doxycycline is contraindicated.
Quinine

Loading dose: Quinine dihydrochloride 20
mg salt/ kg bw diluted in 10 ml/kg bw of 5%
dextrose or dextrose saline administered by
IV infusion over a period of four hours for
both adult and children. In severe Childhood
falciparum malaria, if patient received quinine
or quinidine or mefloquine in 48 hrs before
arrival, give 10 mg/kg over 2 hours.
Quinine
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Maintenance dose: Quinine dihydrochloride 10 mg salt/ kg
body weight diluted in 10 ml/kg body weight of 5% dextrose
or dextrose saline administered by IV infusion. In adults, the
maintenance dose is infused over a period of four hours and
repeated every eight hours.
Similarly in children including congenital malaria, it is
infused over a period of two hours and repeated every
eight hours (calculated from the beginning of the previous
infusion) until the patient can swallow. To complete the
seven-day to eight-day treatment in children, give Quinine
sulfate 10 mg/kg per oral three times in a day. Increase
the dosage of Quinine sulfate to 15-20 mg/kg after 4 days
or add tetracycline 5 mg/kg twice a day for children above
7 years.
Notes
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Artemisinin derivatives are safe, effective, have a wider therapeutic
window, can be administered intramuscularly and should be
considered a safer alternative to quinine.
A loading dose of quinine should not be given (1) if the patient has
received or suspected to have received quinine, quinidine or mefloquine
within the preceding 12 hours, and (2) facilities for controlled rate of flow
of quinine infusion are not available. In order to improve treatment
outcome of quinine add a course of oral tetracycline 4 mg/kg bw 4 times
daily or doxycycline 3 mg/kg bw once daily except for children under 8
years of age and pregnant women, or clindamycin 10 mg/kg bw twice
daily for 3-7 days.
If there is no clinical improvement after 48 hours of parenteral therapy,
the maintenance dose of parenteral quinine should be reduced by onethird to a half (i.e., 5-7 mg/kg bw quinine dihydrochloride). .