Malaria – Treatment
Hematological / Oncological, Infections, Neurological, Special Populations
- A parasitic disease transmitted by the Anopheles Endemic to much of the world and is the leading cause of infectious disease-related death worldwide.
- Five species responsible for human malaria, with Plasmodium falciparum being the most dangerous, and resulting in most cases of severe malaria.
- Falciparum Malaria causes severe organ dysfunction through severe hemolysis causing anemia with intravascular sludging resulting in end-organ ischemia.
- Severe organ dysfunction and death can occur rapidly in patients with severe malaria, and rapid diagnosis and treatment critical.
- If definitive diagnostic tests are unavailable and there is high clinical suspicion for Malaria (especially Falciparum), consult an infectious disease specialist.
- General supportive care measures.
- Anti-malarial therapy should be given under the direction of an infectious disease specialist if possible.
- If a local infectious disease unavailable the Canadian Malaria Network (CMN) is available 24/7. Local CMN contact sites are Vancouver General Hospital, Royal Jubilee Hospital (Victoria), and Kelowna General Hospital but can be accessed from across the province.
- Treatment of uncomplicated malaria:
- Atovaquone-Proguanil (1000mg/400mg) 4 tabs PO daily x 3 days.
- Quinine sulphate 500mg base/600mg salt PO TID x 7 days PLUS.
- Doxycycline 100mg PO BID x 7 days.
- OR Clindamycin 300mg PO QID x 7 days.
- Non-falciparum malaria:
- Chloroquine (1g PO then 500mg PO at 6, 24 and 48 hours) remains first-line therapy for infections acquired outside of chloroquine resistant areas.
- Primaquine (30mg PO daily x 14 days) may be added for chloroquine resistance, or a regimen or atovaquone-proguanil (4 tablets PO daily x 3 days) can be used instead.
- Repeat blood smears are critical to ensure resolution of parasitemia in cases where resistance or dormant infection is possible.
- Treatment of severe malaria ( falciparum):
- Artesunate – parenteral (preferred).
- Faster acting, broader coverage, fewer adverse effects.
- 4mg/kg IV at 0, 12, 24 and 48 hours followed by PO transition.
- Quinine dihydrochloride – parenteral.
- 8mg/kg (base) IV OR 7mg/kg (salt) IV loading followed by 8.3mg/kg (base) OR 10mg/kg (salt) over 4 hours, repeat q8h until PO tolerable.
- Artesunate – parenteral (preferred).
- Patients with severe malaria should ideally receive at least 24 hours of parenteral therapy with clinical improvement prior to transitioning to oral therapy, as directed by your infectious disease specialist.
Criteria For Hospital Admission
- Hospital admission should be considered for the following patients:
- Any child or non-immune adult patient with falciparum malaria.
- Severe malaria.
- Patients with inability to follow-up for further testing and treatment.
Criteria For Transfer To Another Facility
- There are no malaria-specific indications for transfer to another facility, however, in general transfer may be considered if:
- The patient care requirements exceed hospital capabilities (e.g. cardiac monitoring, intensive care, hemodialysis, pediatric/maternal care, etc.).
- Anti-malarial medications are unavailable and cannot be obtained for that facility.
- Specialist consultation is required for other reasons.
Criteria For Close Observation And/or Consult
- All patients with a diagnosis of malaria should be referred to an infectious disease specialist or tropical medicine clinic, or general internal medicine specialist if unavailable.
- All patients with severe malaria require close observation, ideally in a monitored care setting.
Criteria For Safe Discharge Home
- Safe discharge may be considered for the following patients:
- Non-falciparum malaria.
- No signs of end-organ dysfunction.
- Appropriate outpatient follow-up can be arranged.
- If not being admitted, any patient with falciparum malaria should be observed in the ED for administration of their first dose of anti-malarial drugs to ensure the drug is tolerated.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
While there are few high quality randomized controlled trials in this area, there is a significant body of longitudinal research and well-establish Canadian and international guidelines supporting malaria diagnosis and treatment recommendations.
Canadian recommendations on the prevention and treatment of Malaria: Chapter 7 Treatment of Malaria. Public Health Agency of Canada Committee to Advise on Tropical Medicine and Travel (CATMAT).
Canadian recommendations on the prevention and treatment of Malaria: Appendix V Access to Malaria Treatment. Public Health Agency of Canada Committee to Advise on Tropical Medicine and Travel (CATMAT).
Malaria. World Health Organization.
Taylor TE. Treatment of Severe Malaria. In: Post T, ed. UpToDate. Waltham, MA.: UpToDate; 2020.
Daily J. Treatment of uncomplicated falciparum malaria in nonpregnant adults and children. In: Post T, ed. UpToDate. Waltham, MA.: UpToDate; 2020.
RELEVANT CLINICAL RESOURCES
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Sep 23, 2020
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