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Malaria - Coggle Diagram
Malaria
QUININE
Followed by
maintenance
of 10mg/kg by SLOW IV INFUSION over 4 hours, given every 8 hours
Reduce dose by a third only for maintenance dose in those with renal impairment
NB to monitor glucose and vitals + cardiac monitoring if available
Loading dose
of 20mg/kg of quinine dihydrochloride salt by SLOW IV INFUSION over 4 hours
Administer with dextrose to avoid hypoglycaemia
Complete treatment with a full course of artemether-lumefantrine
ONLY if parenteral artesunate not promptly available (or allergy)
Renally eliminated - slower in patients with renal dysfunction (common in malaria)
Gets combined with doxycycline (or clindamycin if doxy is contra-indicated)
Diagnosis
Rapid diagnostic tests
Detect antigen, sensitive & specific in experienced hands
Multiple blood smears
Until diagnosis or asymptomatic
Blood culture
Consider if also worried about bacterial sepsis or typhoid
FBC
e.g. low platelet count is often hint
Test for malaria in anyone with travel history to malaria area + illness
U&E + glucose
ARTESUNATE
Has excellent safety & tolerability
Adverse reactions
: GI disturbances (N&V, anorexia) and dizziness
Delayed haemolysis starting >1 week after artesunate treatment of severe malaria in hyperparasitaemic patients has been reported - must be followed up carefully to identify & treat late-onset anaemia
Few patients develop hypoglycaemia, cardiac monitoring is not required
Dose
: 2.4mg/kg (or 3mg/kg if <20kg) IV at 0, 12 & 24 hours, then daily until patient able to tolerate oral treatment
Areas where malaria can be controlled
Parasite
(asexual/gametocytes) - antimalarial drugs
Poverty-related
- economic development
Mosquito
(anopheles) - vector control
Signs & symptoms
Uncomplicated
Other: anaemia, back pain, motor weakness, joint paint, thirst, poor appetite, abdominal pain, N&V, diarrhoea
Fever (& chills, sweating), fatigue, headache
Severe
Impaired consciousness, convulsions, shock, circulatory collapse (weak, rapid pulse), respiratory distress, pulmonary oedema, jaundice, extreme weakness (unable to sit or stand), anuria/haemoglobinuria, abnormal bleeding, severe dehydration
Investigations: severe anaemia, hypoglycaemia, acidosis, renal impairment, hyperlactataemia, hyperparasitaemia, hyperbilirubinaemia
Very non-specific - often misdiagnosed
Uncomplicated malaria
Artemether-lumefantrine
(Trade name: Coartem)
Active against asexual blood stages & gametocyte stage (sexual - plays role in transmission)
When not to use: allergic to artemisinins / lumefantrine, <5kg, severe malaria, pregnant in 1st trimester
Weight based dosing
Treatment invovles 6 doses over 3 days, must be taken with food or milk containing >1.2g of fat - helps with absorption
Key info if unable to admit
Advice on how to take medication
Advise about fluids, temp control with paracetamol (not NSAIDs / aspirin)
Compliance with full course of Coartem
Expect response within 24-48hrs, return if temp not settling by day 3 or if remains unwell
Tell patient to return immediately if vomiting or deteriorates in any way (e.g. becomes sleepy/confused)
Special risk outpatients that should be seen daily / preferably admitted
Young children (especially if malnourished)
Elderly
Comorbidities e.g. HIV co-infection (especially if on
efavirenz
or
rifampicin
, as this reduces Coartem concentrations)
PRIMAQUINE
Used in treatment of P. ovale and P. vivax - treats latent parasite in the liver
Taken daily for 14 days
Contra-indicated in pregnancy, must wait for end of pregnancy before treating
Treatment decisions
Uncomplicated or severe?
Any risk factors?
Vomiting, pregnant, young children, underweight for age, co-morbidities (e.g. HIV)
Ancillary treatments
NO
Aspirin/NSAIDs, heparin, corticosteroids, mannitol
YES
Oxygen, antipyretics (paracetamol), anticonvulsants, consider antibiotics, blood transfusion, mechanical ventilation, haemofiltration/dialysis, exchange transfusion
Severe malaria
Principles of management
Admit to highest level of care available
Monitor: vitals & glucose 4hrly, watch fluids, daily electrolytes & smears
Urgent parenteral antimalarial treatment (with one positive rapid & any features of severe malaria)
IV
artesunate
(strongly preferred) - in both adults and children
IV
quinine
- loading dose, then slow rate-controlled infusion
Artemether-lumefantrine - important that full course of 6 doses is completed
Manage convulsions / fever, support failing organs
Rapid assessment of organ function
HB, U&E, blood glucose, lactate
CNS, jaundice, renal, cardiac, respiratory, bleeding, anaemia
Decreased LOC - check glucose / give empiric glucose
Causative organism
Plasmodium falciparum, P vivax, P ovale and P malariae
Treatment failure
Causes
Adherence, malaria diagnosis, drug quality, concomitant meds, comorbidities, sub-optimal dosing, antimalarial resistance