Algorithm for the treatment of malaria in adults
Triage
• Urgently assess all febrile/ill patients who traveled to a malaria area in the past 6 months (incubation for
nonfalciparum infection occasionally >6 mo)
• Within 3 weeks of return, discuss infection control requirements (eg, VHF, avian influenza, or SARS) with
microbiologist but do not delay blood film
Early diagnosis and assessment of severity is vital to avoid malaria death
Key points in the history and –no symptoms/signs can accurately predict malaria
• Symptoms are nonspecific; may include fever /sweats/chills, malaise, myalgia, headache, diarrhea, cough, jaundice, confusion,
• Consider country of travel, stopovers, date of return; falciparum malaria most likely to occur within 3 months of return; could be longer in
those who have taken chemoprophylaxis or had partial treatment. Incubation period for malaria is >6days
• Consider type of malaria prophylaxis used (ie, drug, use, adherence); correct prophylaxis with full adherence will not exclude malaria.
• Consider other related- travel infections (eg, typhoid fever, hepatitis, dengue fever, avian influenza, SARS, HIV, meningitis, VHF)
• Examination findings are nonspecific
Urgent investigations for all patients If P. falciparum is confirmed
• Thick –and thin –blood films and rapid antigen malaria test. Send for laboratory immediately, ask for results within 1 hour • Ask the laboratory to estimate the
• CBC for thrombocytopenia, urea and electrolytes, LFT’s, blood glucose parasite count
• Clotting screen, arterial blood gases
• Blood culture(s) for typhoid or other bacteremia
12‐lead ECG (complicated malaria)
• Urine dipstick (for hemoglobinuria), culture. If patient has diarrhea, send feces to microscopy and culture • Do pregnancy test if appropriate;
• Chest radiograph to exclude community acquired pneumonia high risk of sever malaria in preg.
BLOOD TEST SHOWS
Nonfalciparum malaria Falciparum malaria No evidence of malaria
• P Vivax Outpatient therapy is usually • P falciparum A single negative film and/ or antigen
• P ovale appropriate depending on • Mixed infection does not exclude malaria
• P malariae clinical judgment • Species not characterized
Admit all cases to hospital
Assess severity on admission • Stop prophylaxis until malaria
excluded
• Avoid empirical therapy for malaria
Nonfalciparum antimalarials Complicated malaria, 1 or more of these: unless patient severely ill
Chloroquine (base) 600 mg, then 300 mg at • Impaired consciousness
6, 24, 48 hrs. In P vivax and P ovale after • Hypoglycemia
treating acute infection, use primaquine • Parasite count >2%
(30 mg/d base for P vivax , 15 mg/d base • Hemoglobin < 8g/dl • Blood films daily for 2 more days
for P ovale) for 14 days to eradicate liver • Spontaneous bleeding /DIC • Malaria unlikely with 3 negative
parasites; G6PD should be measured • Hemoglobinuria (without G6PD deficiency) blood films. Consider other
before administering primaquine, seek • Rena impairment or electrolyte/acid‐ base disturbance travel/non‐travel illness
expert advice if low • Pulmonary edema or adult respiratory distress syndrome • Finish chemoprophylaxis
• Shock (algid malaria); may be due to gram –ve bacterimia
Falciparum antimalarial uncomplicated Essential features of general management Falciparum antimalarials: complicated
• Oral quinine 600 mg every 8 hrs plus • Commence antimalarial immediately or if patient is vomiting
doxcycycline 200 mg/d (or Severe malaria • Either quinine 20mg /kg loading dose
clindamycine 450 mg every 8 hrs) for 7 • Consider admission to ICU (no loading dose if patient taking
days • Seek early expert advice from tropical quinine or mefloquine already) as IV
Or disease/infectious disease unit physician in 5% dextrose over 4 hrs, then
• Mefloquine684 mg base (=750 mg salt) • Oxygen therapy 10mg/kg every 8 hrs for first 48
po as initial dose, followed by 456 mg • Carful fluid balance hours (or until the patient can
base (=500 mg salt) po given 6‐12 • Monitor blood glucose regularly (especially during swallow) when oral quinine sulphate
hours after initial dose IV quinine therapy) 600 mg should be given 3 times a
Total dose= 1,250 mg salt • ECG monitoring (especially during IV quinine day to complete 5‐7 days of quinine
Co‐artem (Riamet): if weight > 35 kg, 4 therapy ) in total, plus oral doxcycycline 200
tablets, then 4 tablets at 8, 24, 36, 48, • Observation every 4 hrs until stable (i.e., pulse, mg/d for 7 days(in pregnancy use
and 60 hrs temperature, BP, urine output ) regular medical clindamycine 450 mg every 8 hours.
• Atovaquone/proguanil HCI (Malarone) review until stable Maximum quinine dose, 104g
4 “standard” tablets for 3 days • Repeat CBC , clotting , urea and electrolyte , LFTs , • Or if available: artesunate IV 2.4
Reference parasite count daily mg/kg at 0,12,24 hrs, then daily to
1. Current WHO guidelines 2006 • In shock treat for gram negative bacteremia complete a course of 7days plus
2. UK malaria treatment guidelines doxcycycline and clindamycine as
3. CDC malaria treatment guidelines above
