Treatment Guidelines for Malaria Contd...

Treatment regimens for uncomplicated malaria in adults

_ Oral quinine sulphate 600 mg/8 h for 5e7 days plus doxycycline 200 mg daily (or clindamycin 450 mg/8 h for pregnant women) for 7 days

_ Atovaquoneeproguanil (Malarone_): 4 ‘standard’ tablets daily for 3 days or

_ Co-artem ((artemetherelumefantrine_): if weight > 35 kg, 4 tablets then 4 tablets at 8, 24, 36, 48 and 60 h

 Child Initial dose 10 mg/kg/base then 5 mg/kg base 6e8 h later and on days 2 and 3

 However, both of these newer regimens need to be taken for only 3 days. In contrast, quinine needs to be taken for 5e7 days and is often associated with ‘‘cinchonism’’ (nausea, deafness and ringing in the ears), which often results in poor adherence. Although international recommendations suggest that quinine should be taken for 7 days in endemic areas,2 UK experience suggests  that 5 days treatment is adequate for the vast majority of cases. Quinine should be combined with a second drug (doxycycline for adults or clindamycin in pregnant women and young children) to ensure complete eradication of parasites.

 Drug treatment of severe or complicated malaria

_ Quinine: loading dose of 20 mg/kg quinine dihydrochloride in 5% dextrose or dextrose saline over 4 h. Followed by 10 mg/kg every 8 h for first 48 h (or until patient can swallow). Frequency of dosing should be reduced to 12 hourly if intravenous quinine continues for more than 48 h.

_ Alternative rapid quinine loading regimen (adults only) 7 mg/kg quinine dihydrochloride over 30 min using an infusion pump followed by 10 mg/kg over 4 h.

_ Parenteral quinine therapy should be continued until the patient can take oral therapy when quinine sulphate 600 mg should be given 3 times a day to complete 5e7 days of quinine in total.

_ Quinine treatment should always be accompanied by a second drug: doxycycline 200 mg (or clindamycin 450 mg 3 times a day for pregnant women, 7e13 mg/kg 3 times a day for children), given orally for total of 7 days from when the patient can swallow.

_ Artesunate regimen: appropriate for adults only on expert advice. 2.4 mg/kg given as an intravenous injection at 0, 12 and 24 h then daily thereafter. A 7-day course of doxycycline should also be given.

 Intensive care management of severe or complicated malaria

_ Careful management of fluid balance to optimise oxygen delivery and reduce acidosis

_ Monitoring of central venous pressure to keep right atrial pressure <>

_ Regular monitoring for hypoglycaemia 

_ Consider broad spectrum antibiotics if evidence of shock or secondary bacterial infection

_ Haemofiltration for renal failure or control of acidosis or fluid/electrolyte imbalance

_ Consider medication to control seizures

_ Consideration of exchange transfusion in patients with hyperparasitaemia

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