INDEX

    Malaria – Treatment

    Hematological / Oncological, Infections, Neurological, Special Populations

    Last Updated Sep 23, 2020
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    Context

    • 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.

    Recommended Treatment

    • 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:
      • falciparum:
        • 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.
    • 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?

    Justification

    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.

    Moderate

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