Malaria, Plasmodium falciparum, Plasmodium vivax chloroquine, Coartem, quinine

1. HOW TO MANAGE
MALARIA IN A OUT-PATIENT
CLINIC IN ETHIOPIA
Dr. Dino Sgarabotto
Malattie Infettive e Tropicali
Azienda Ospedaliera di Padova

2. MALARIA
• The most serious and life-threatening disease occurs
from Plasmodium Falciparum infection, which usually
presents with acute fever, chills, sweating and
headache
• It can progress to jaundice, coagulation defects, shock,
renal and liver failure, acute encephalopathy,
pulmonary and/or cerebral edema, coma and death.
• Prompt diagnosis and treatment is essential even in
mild cases to prevent complications.

3. Other species
• Plasmodium vivax (benign tertian),
Plasmodium malariae (quartan) and
Plasmodium ovale, are not life-threatening,
except in:
– the very young,
– very old,
– immuno-deficient cases

4. Standard Diagnosis
• Smear microscopy remains the most
important diagnostic tool:
– Thick and thin blood film stained with MGG
It is also helpful to estimate the
degree of parasitemia, which is
extremely useful not only to
predict severity but also
response to treatment as well.

5. Thin blood film
x100
Thick blood film
x100
Plasmodium falciparum
Plasmodium vivax

6. New diagnostic kits
• Similar to urine pregnancy test, but the
malaria diagnostic kits are performed from 12 drops of blood
Positive

7. Uncomplicated
P. falciparum malaria
• First line treatment
• Artemether + Lumefantrine, 80 + 480mg P.O.
BID for 3 days
• S/Es: nausea, vomiting, diarrhea
• C/Is: first trimester pregnancy
• Dosage forms: Tablet, 20mg +120mg
• Total number of tablets: 24 (Coartem 4 Tabs
BID for 3/7)

8. Uncomplicated
P. falciparum malaria
• Alternative treatment
• Quinine sulphate, 600 mg TID for 7 days.
• S/Es: Cinchonism, including tinnitus, headache,
nausea, abdominal pain, rashes, visual disturbances,
confusion, blood disorders (including
thrombocytopenia and intra-vascular coagulation),
and acute renal failure.
• C/Is: Hemoglobinuria, optic neuritis
• Dosage forms: Tablet 300mg and 600mg;
injection, 300mg/ml in 1 ml ampoule.

9. Pediatric Dosing
Body Weight
Artemether/Lumefantrine (CoartemTM) Pediatric Dosing
5 kg to < 15 kg
1 tablet at hour 0 and at hour 8 on the first day, then 1 tablet
twice daily (in the morning and evening) on days 2 and 3
(total of 6 tablets per treatment course)
15 kg to < 25 kg
2 tablets at hour 0 and at hour 8 on the first day, then 2
tablets twice daily (in the morning and evening) on days 2
and 3 (total of 12 tablets per treatment course)
25 kg to < 35 kg
3 tablets at hour 0 and at hour 8 on the first day, then 3
tablets twice daily (in the morning and evening) on day 2 and
3 (total of 18 tablets per treatment course)
≥35 kg (adult dosing) 4 tablets at hour 0 and at hour 8 on the first day, then 4 tablets
twice daily (in the morning and evening) on days 2 and 3
(total of 24 tablets per treatment course

10. Severe and complicated
P. falciparum malaria
• Non-Drug treatment
•
Clear and maintain the airway; Position semi-prone or on side; Weigh
the patient and calculate dosage; Make rapid clinical assessment.
• Exclude or treat hypoglycemia (more so in pregnant women).
• Assess state of hydration. Measure and monitor urine output.
– 1. If necessary insert urethral catheter.
– 2. Measure urine specific gravity.
• Take blood for diagnostic smear, monitoring of blood sugar ('stix'
method), haematocrit and other laboratory tests.
• Plan first 8 hrs of intravenous fluids including diluents for anti-malarial
drug, glucose therapy and blood transfusion.
• If rectal temperature exceeds 39°C, remove patient's clothes, use tepid
• sponge,
• Lumbar puncture to exclude meningitis or cover with appropriate
antibiotic.
• Consider other infections.
• Consider need for anti-convulsant treatment

11. Severe and complicated
P. falciparum malaria
• Drug Treatment
• Quinine dihydrochloride: Loading dose 20 mg/kg in 500
ml of isotonic saline or 5 % dextrose over 4 hours (4
ml/minute). The pediatric dose is the same but the fluid
replacement must be based on body weight.
• Maintenance dose should be given 8 hours after the loading
dose at 10 mg / kg and it should be given 8 hourly diluted in
500 ml of isotonic saline or 5 % dextrose over 4 hours.
• The parenteral treatment should be changed to P.O. as soon
as the patient‘s condition improves and if there is no
vomiting. Oral treatment should be given with Artemether +
Lumefantrine in the doses as indicated above. However, if a
patient has a history of intake of Artemether + Lumefantrine
before complications developed, give Quinine tablets 10 mg
salt per kg TID tocomplete 7 days treatment.

12. P. vivax malaria
• Chloroquine phosphate, 1 g, then 500 mg
in 6 hours followed by 500 mg QD for 2 days,
i.e.: Chloroquine 250 mg 4 Tabs stats, then 2 tabs
after 6 hours, then 2 tabs OD for 2/7 (totale 10
Tabs)
• or 1 g at 0 and 24 hrs followed by 0.5 g at 48
hrs P.O, i.e.: Chloroquine 250 mg 4 Tabs stats,
then 2 tabs OD for 2/7 (totale 8 Tabs)
• Pruritus is not uncommon in persons with
darker skin pigmentation.

13. In P. vivax malaria
• Chloroquine should be followed by
Primaquine, 15mg base P.O. 1 Tab OD for 14
days.
• S/Es: Nausea, vomiting anorexia, and less
commonly hemolytic anemia, especially in
patients with G6PD deficiency.
• P/Caution: In patients with G6PD deficiency;
systemic diseases associated with
granulocytopenia, e,g. rheumatoid arthritis, and
pregnancy and breast feeding)
• Dosage forms: Tablet, 7.5mg base, 15mg base

16. THANK YOU!
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