Management of Malaria

Malaria is one of the leading causes of death in India, especially in the rural areas due to standing water bodies and lack of diagnostic and treatment facilities. It is important that persons who are exhibiting signs and symptoms of malaria are treated timely and provided blood and component assistance. India along with Pakistan and Ethiopia accounts for 80% of the malaria deaths in the world, according to a WHO report. Malaria is usually caused due to the bite of the Plasmodium Falciparum female mosquito. Hence it is important to know about how the mild and complicated facets of the infection can be managed.

How to Manage Mild P. Falciparum Malaria Infection?

• Since P. Falciparum is now resistant to chloroquine and sulfadoxine-pyrimethamine (Fansidar) almost world-wide, an artemisinin-based treatment is recommended. Co-artemether (CoArtem or Riamet) contains artemether and lumefantrine and is given as 4 tables at 0, 8, 24, 36, 48 and 60 hours.
• Alternatives are quinine by mouth (600mg of quinine salt 3 times daily for 5-7 days), together with or followed by either doxycycline (200 mg once daily for 7 days) or clindamycine (450mg 3 times daily for 7 days) or atovaquone proguanil (Malarone, 4 tablets once daily for 3days).
• Doxycycline should not be used in pregnancy and artemether should be avoided in early pregnancy.
• WHO policy in Africa is moving towards always using artemisinin-based combination therapy (ACT), e.g. co-artemether or artesunate-amodiaquine. In India and other areas, artesunate (200mg orally daily for 3 days) and mefloquine (1 g orally on day 2 and 500 mg orally on day 3) may be used. Unfortunately, artemisinin resistance has now been reported in Cambodia.

How to Manage Complicated P. Falciparum Malaria Infection?

• Severe malaria should be considered in any non-immune patient with a parasite count greater than 2% as a medical emergency. Management includes early and appropriate antimalarial chemotherapy, active treatment of complications, correction of fluid, electrolyte and acid-base balance and avoidance of harmful ancillary treatments.
• The treatment of choice is intravenous artesunate given as 2.4 mg/kg IV at 0, 12 and 24 hours and then once daily for 7 days.
• However, as soon as the patient has recovered sufficiently to swallow tablets, oral artesunate 2mg/kg once daily is given instead of intravenous therapy, to complete a total cumulative dose of 17-18 mg/kg.
• Rectal administration of artesunate is also being developed to allow administration remote rural areas.
• Quinine salt can also be used and is started with a loading dose infusion of 20mg/kg over 4 hours, up to a maximum of 1.4 g. This is followed by maintenance doses of 10mg/kg quinine salt given as 4-hour infusions 2-3 times daily, up to a maximum of 700 mg per does, until the patient can take drugs orally. The loading dose should not be given if the patient has received quinine, quinidine or mefloquine during the previous 24 hours.
• Patient should be monitored by ECG, with special attention to QRS duration and QT interval. Mefloquine should not be used for severe malaria since no parenteral form is available.
• Exchange transfusion has not been tested in randomised controlled trials but may be beneficial for non immune patients with persisting high parasitaemias (>10% circulating erythrocytes).