Falciparum malaria can create severe complications. Antimalarial drugs such as quinine or chloroquine help in the treatment and management to these complications. The use of chemoprophylaxis is a must for persons travelling abroad to countries subject to malaria, but one must not assume that chemoprophylaxis, even though taken regularly will protect against malaria.peer-reviewe

Gilles, Herbert M.

English

OAR@UM

Maltese Medical Journal 9 Winter Issue '88/89 The Management and Treatment of Malaria H.M. Gilles, B.5c., M.D., D.5c. (Hon. Causa: Malta), M.5c. (Oxon.)., F.R.C.P. (Lond.), EEC.M. (U.K.)., EM.C.P.H. (Nigeria)., D.Med.Se. (Hon. Causa: Karolinska Institute, Stockholm)., D.T.M. & H.- Emeritus Professor of Tropical Medicine, University of Liverpool. Formerly professor of Tropical Medicine, and Dean, Liverpool School of Tropical Medicine. The package tour holiday industry, the expansion of international trade and the speed of travel are all playing a major role in the problem of 'imported diseases' , espe­cially as tourists are becoming increasingly adventurous and travelling to more remote and exotic places year by year. Of all the travel-associated diseases malig­nant tertian malaria due to Plasmodium fal­ciparum is the most important. There is no other ' tropical' illness that changes so dram­atically from a relatively benign infection to a catastrophic and fatal one in the space of a few days. In 1987 in Britain, 7 deaths due to P.falciparum were recorded and up to July 1988 already 3 deaths had occurred. All the fatalities were due either to misdiagnosis or delayed treatment. Unless practitioners become aware of this problem, however rare in their experience it may be, unnecessary deaths will continue to occur. The simple routine habit of eliciting a recent geographi­cal history has yet to become accepted good medical practice in many non-endemic malarious areas of the world. Unde Venis viator et quo vadis? ' 2 'Airport' malaria is now well documented:'. It occurs in persons working or living near airports, recipients of flights from Africa in particular. Chloroquine and indeed multidrug resist­ant malaria is one of the most worrying developments of recent years, especially as it has now established a firm foot-hold in Africa South of the Sahara, in several coun­tries where P.falciparum transmission is hyperendemic, and basic health services relatively poorly developed.' The chemotherapy and management of malaria have recently been reviewed.' h 7 The approach is a two-pronged one - chemo­therapeutic and supportive - both are equally important, and common errors should be avoided. a. COMMON ERRORS IN THE MANAGEMENT OF SEVERE P. FALCIPARUM MALARIA. 1) 	 Failure to take a travel history 2) 	 Assumption that chemoprophylaxis is completely protective 3) 	 Failure to consider 'induced' malaria ­i.e. 	 blood transfusion and contami­nated needles 4) Misjudgment of severity 5) Poor standard oflaboratory diagnosis 6) Missed hypoglycaemia 7) Errors of fluid and electrolyte balance 8) Inadequate nursing care 9) Failure to control convulsions 10) Failure to recognise and treat severe anaemIa 11) 	 Use of potentially dangerous ancil­liary therapies, e.g. corticosteroids, heparin 12) 	 Delay in starting haemo or peritoneal dialysis b. THE MANAGEMENT OF THE SEVERE MANIFESTATIONS OF FALCIPARUM MALARIA IS GIVEN IN TABLE 1. Table I. Severe complications of falciparum malaria and their management (After WHO 1989 - in press) Complication 1. Coma (cerebral malaria) 2. 	 Hyperpyrexia 3. Convulsions 4. 	 Severe anaemia (packed cell volume less than 20%) 5. 	 Acute pulmonary oedema 6. 	Acute renal failure 7. 	 Spontaneous bleeding and coagulopathy 8. 	 Metabolic acidosis 9. 	Hypoglycaemia 10. 	Gram-negative septicaemia ("Algid malaria") 11. Aspiration pneumonia 12. Hyperparasitaemia (> 20%) Management* Maintain airway, nurse on side, exclude other treatable causes of coma(e.g., bacterial meningitis). Avoid harmful adjuvant treatments such as corticosteroids, heparin and adrenaline. Tepid sponging, fanning, dipyrone injection. Maintain airway, diazepam or paraldehyde injection (Prevent with phenobarbital intramusculary - 3.5 mg/kg one single dose on admission) Transfuse fresh whole blood or packed cells Prop up at 45°, give oxygen, venesect 250 ml of blood into donor bag, give diuretic, stop intravenous fluids. Exclude dehydration: strict fluid balance, peritoneal dialysis (haemodialysis if available). Transfuse fresh whole blood, vitamin K injection. Exclude or treat hypoglycaemia, hypovolaemia and Gram-negative septicaemia. Give oxygen. Give 50% dextrose injection followed by 5% to lO'lf, dextrose infusion. Give parenteral antimicrobials, correct haemo­dynamic disturbances. Give parenteral antimicrobials, change position, physiotherapy, give oxygen. Exchange transfuse 4 or more units of fresh whole blood It is assumed that quinine or chloroquine infusion will have been started in all cases. L-________________________________________________________________________-J!~ ______________________________________________________________________ Maltese Medical Journal I I Winter Issue '88/89 ~ C. 	 ERRORS OF ANTIMALARIAL CHEMOTHERAPY 1) 	 Delay in starting treatment 2) 	 Incorrect dosage 3) 	 Inadequate dosage 4) 	 Inappropriate route of administration e.g. "bolus" injection intravenously 5) Failure to control the rate of intrave­nous infusions -6) Failure to switch patients from paren­teral to oral therapy as soon as they can swallow d.THE CHEMOTHERAPY OF P. 	FALCIPARUM MALARIA8 Quinine is the treatment of choice:­(i) 	 In areas of the world where chloro­quine resistance is established or suspected (ii) 	 In cases of doubt as to the origin of the malaria or the existence of resistance (iii) 	 Where malaria has been acquired des­pite chloroquine prophylaxis. The drug is given orally in uncomplicated cases or by slow intravenous infusion in severe malaria. Chloroquine is an effective treatment if the parasite is fully sensitive to the drug. Unfor­tunately, in many of the malarious coun­tries this is no longer the case. However, if the cinchonal alkaloids - quinine or quini­dine - are not available, chloroquine can be life-saving since it will reduce parasitaemia if resistance is at the RI or RII level. Antimalarial chemotherapy is summarised in Table n. Table n. Antimalarial drugs for the Uncomplicated infections (able to swallow tablets) Chloroquine-sensitive areas (and areas of Plasmodium vivax, Plasmodium ovale l and Plasmodium malariae) Chloroquine base, 600 mg immediately, followed by chloroquine base, 300 mg 8 hours later and daily on days 2, 3 and 4 Chloroquine resistant areas (1) 	 Quinine 600 mg (salt) 8 hourly for 7 days plus single dose of Fansidar 3 tablets, i.e. (Sulfadoxine 1500 mg + pyrimethamine 75 mg)" OR (2) 	 Quinine, 600 mg (salt) 8 hourly for 7 days plus tetracycline", 250 mg 6 hourly for 7 days OR (3) 	 Mefloquine, 1000 mg (salt) single doseL NOTES 1. 	 For P.vivax and P.ovale infections add primaquine, 15 mg daily for 14-21 days 2. 	 Sulpha-antifolate resistance is wides­pread, therefore check current pattern of drug resistance. 3. 	 Tetracycline should not be given to chil­dren under 8 years or pregnant women. 4. 	 Quinidine can be substituted for qui­nine. ECG changes (prolongation of the QT interval) and hypotension will occur, so these effects should be monitored. 5. 	 A loading dose should not be used if quinine has been given in the previous 12 hours. As soon as the patient can swallow tablets quinine 600 mg (salt) 8 hourly for 7 days should be substituted or preferably an oral dose of 1000 mg (salt) ofmefloquine is given either as a single dose or in two divided doses 500 mg each dose at an interval of 6 hours. The latter regimen may reduce the possibility of vomiting. CHEMOPROPHYLAXIS Several basic points must be emphasized ­1. It must never be assumed that chemo­prophylaxis, even when taken regularly, will al ways protect against malaria - protec­tion is relative. Thus, every non-immune person residing temporarily or for longer periods in a malarious area must be warned that, if he feels ill, malaria must still be excluded as a possible diagnosis. This is par­ticularly relevant because of the spread of resistance to many antimalarial drugs and the absence of accurate and comprehensive TIlaps of the distribution of resistance to the antimaliarials in current use. Evidence of resistance . based on 'clinical' experience often without concomitant and competent microscopic diagnosis ofmalaria has aggra­vated an already complex situation. 2. 	 Accept with the greatest scepticism that treatment of malaria in adults Complicated infections Chloroquine-sensitive areas Chloroquine 5 mg base/kg i.v. infusion given over 4-6 hours, every 12 hours (total dose 25mg/ kg) Chloroquine· resistant areas Quinine dihydrochloride' 20 mg salt/kg loading dose-' i. v. infusio n gi ven 0 ver 4 hours, followed by 10 mg/kgi. v. infusion given over 4 hours every 8 hours (intra­muscular injection into the lateral thigh can be used if intravenous infusion is impossible). any potentially malarious area is free from risk. Anecdotes that in West Africa, for example, cities are malaria free are quite inaccurate. 3. Malaria can be acquired at relatively short stops on a journey, for example, while refuelling the aeroplane. 4. It is important to have adequate blood levels of antimalarials by the time a person is at risk. This can be achieved by taking a dose the day before departure. Despite this, it is considered wise to begin antimalarials 1 week before travelling in order to get used to the habit and to detect rare cases of idiosyncrasy. 5. Antimalarial chemoprophylaxis must be continued for 4 weeks after returning from an endemic area and the need to conti­nue must be stressed. 6. It is important to remember that PIal­ciparum can recrudesce for 1 year and P.vivax up to 5 years. Any fever occurring during this period should be suspected to be malaria until the contrary is proved, irres­pective of whether the person has been on chemoprophylaxis or not. 7. Special risk groups, such as pregnant women, infants, over 70 year old, immuno­deficient patients or those on other long­term medication, should seek up-to-date advice on the appropriate prophylaxis from specialized centres in their respective countries. The regiments for chemoprophyalaxis cur­rently recommended in Britain are given in Table Ill. Table IlL Chemoprophylaxis regimens for short-term « 4 weeks) travellers Countries where Plasmodium falciparum is sensitive to chloroquine (North Africa!, the Middle Eastl, and Cen­tral America) Chloroquine, 300 mg base (2 tablets) once weekly OR Proguanil hydrochloride, 200 mg daily Countries where Plasmodium falciparum is resistant to chloroquine (all countries except those above and the 'hard-core; countries below) Chloroquine, 300 mg base (2 tablets) once weekly (for P.vivax infections) plus progua­nil hydrochloride, 200 mg daily 'Hard-core' Plasmodium falciparum multi­drug resistant countries (Thailand, Laos, Kampuchean border areas, South Vietnam, Papua New Guinea, rural areas of the Philippines) Pyrimethamine plus dapsone (Maloprim), one tablet weekly plus chloroquine, 300 mg base (2 tablets) weekly OR Mefloquine (if available), 250 mg once weekly ~____________________~~~::~~i7~I~ cont. on pgA7 Maltese Medical Journal 47 Winter Issue '88/89 cont. from pg.ll NOTE 1 Malaria transmission in North Africa and the Middle East is low, focal, seasonal and predominantly due to P.uiuax. Chemo­prophylaxis is not essential providing prompt treatment is sought in the event of an illness occurring 10 days after exposure. Long-term travellers and non-immune resi­dents of malarious areas should follow the same regimen as 'short-term' travellers unless advised otherwise by the competent authorities in the countries concerned. SELF TREATMENT Under certain conditions self-treatment is not only permissible, but justified. It is man­datory, however, that this practice should not be abused. Standby antimalarial agents for 'self-treatment' are pyrimethamine plus sulfadoxine (Fansidar), or in very special circumstances mefloquine (if available). Treatment for malaria should not be consi­dered until at least 10 days have elapsed after entering an endemic area (the incuba­tion period of Pfalciparum malaria is usu­ally 10-12 days). PERSONAL PROTECTION Personal protection has become as impor­tant as taking antimalarial drugs. Some basic measures for reduction of exposure to mosquito bites are: Use of mosquito nets Screening of houses Use of repellants Spraying of rooms before retiring to bed Use of mosquito coils Adequate clothing (e.g . long sleeves and trousers in the evenings) SUMMARY A review of the modern management and chemotherapy of malaria, the most impor­tant parasitic disease in the world. REFERENCES 1. 	 Bruce-Chwatt, L..J., Unde venis viator et quo vadis? Ann.Trop.Med.Parasit. 1987; 81: 471-486 2. 	 Maegraith, B.G. Unde venis? Lancet, 1963; 1 : 401-403 3. 	 Gilles, H.M. Malaria. Medicine Interna­tional. 1984; 2 : 141-145 4. 	 Gilles, H.M. Malaria - An overview. J .Inf. 1988 (in press) 5. 	 Warrell, D.A. Clinical management of severe falciparum malaria. Act. Leid. 1987; 55 : 99-113 6. 	 White, N.J. The treatment of falciparum malaria. Parasit. Today. 1988; 4 : 10-15 7. 	 Giles, H.M. The treatment and prophy­laxis of malaria. Ann.trop.Med.Parasit. 1987; 81 : 607-617 8. 	 Phillips, R.E., Gilles, H.M. Malaria. Medicine International. 1988; 54 : 2220­2225 The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation. Users may access this full-text article and can make use of the information contained in accordance with the Copyright Act provided that the author must be properly acknowledged.  Further distribution or reproduction in any format is prohibited without the prior permission of the copyright holder. This article has been reproduced with the authorization of the editor of the Malta Medical Journal (Ref. No 000001)  

Clinical management of severe falciparum malaria.

The treatment and prophy laxis of malaria.

The treatment of falciparum malaria.

Unde venis viator et quo vadis? Ann.Trop.Med.Parasit.

The management and treatment of malaria

https://www.um.edu.mt/library/oar/bitstream/handle/123456789/677/mmj010109.pdf?sequence=3&isAllowed=y

The management and treatment of malaria

Abstract

Similar works

Full text

Available Versions

OAR@UM