Malaria Site: Guidelines for Management of Malaria in Dakshina Kannada

History, Aetiology, Pathophysiology, Clinical Features, Diagnosis, Treatment, Complications And Control Of Malaria

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Guidelines for Management of Malaria in Dakshina Kannada

Introduction: Malaria is on the rise once again with the arrival of monsoon. The thrust of the Malaria Control Programme is to minimise morbidity and mortality from malaria and we seek your fullest co-operation. The World Health Organization has also greatly emphasized the importance of Early Diagnosis and Prompt Treatment in reducing the parasite load in the community and thereby in malaria control.

Clinical features of malaria include fever, chills, rigors, headache, vomiting etc. and in a typical case, these occur in paroxysms once in 48 hours. However in an endemic area, it is common to find patients with atypical manifestations like severe headache, giddiness, chest pain, acute abdominal pain, diarrhoea, vomiting, jaundice, cough, breathlessness, 'weakness' and hypotension etc., with or without fever. Therefore, it is always wiser to get a blood test for malaria parasites in all doubtful cases. Do not wait for chills or rigors to do MP Test.

Diagnosis of malaria is made by either peripheral smear examination or by the QBC technique. The QBC technique is faster and more sensitive, but identification of the species and assessment of severity is difficult or even impossible. Therefore, when in doubt, ask for a peripheral smear. The new rapid diagnostic tests for malaria (Dip Stick RDTs) may not be reliable due to occurrence of false positive, false negative results and cross reaction between asexual and sexual forms of the parasite as well as between different species.

Complications of P. falciparum Malaria: P.falciparum can cause various organ dysfunction resulting in dramatic and life threatening complications. Hyperpyrexia, pallor, jaundice, prostration, breathlessness, CNS manifestations, oliguria, hypotension etc., are indicators of complications. Patients at extremes of age, pregnant, alcoholics and patients developing malaria for the first time are prone for these complications. All cases of complicated P. falciparum malaria should be admitted and treated.

Please keep the following in mind:

Consider malaria in all cases of fever and/or atypical presentations listed above. Please get the blood tested for malaria in ALL cases of fever and in all doubtful cases.

Administer presumptive antimalarial treatment (See below for NEW recommendations) to ALL cases of fever AFTER sending for their blood test. Presumptive treatment helps by providing early relief and by destroying the P. vivax as well as P. falciparum gametocytes, hence preventing the spread.

Administer PRIMAQUINE to ALL cases of proven malaria. In P. vivax and mixed infections, it should be given for 5 days (as tissue schizonticidal to prevent relapse) and in P. falciparum infection, a single dose is enough (as gametocytocidal). Failure to administer primaquine leads to increased transmission of malaria.

Ensure adequate dosage and complete treatment. In case the patient vomits within one hour of administration of the drugs, the same should be re-administered

It takes at least 48 hours for the patient to be afebrile after starting the treatment. If the patient continues to be febrile even after 72 hours, consider other possibilities.

Primaquine cannot be used in pregnancy and first 6 months of lactation and hence put them on weekly Chloroquine 500 mg as suppressive chemotherapy. Once the mother decides to discontinue breast-feeding, treat the mother with full dose of chloroquine and primaquine.

Repeat blood smear should be done on the 6^th day in all cases of malaria (to confirm response to therapy) and on the 14^th and 28^th day in cases of P. falciparum (to look for early and late recrudescence).

Recurrence of malaria could be due to relapse (in case of P. vivax), recrudescence (in case of P. falciparum) or re-infection. Re-infection is the most common cause for recurrence and can occur any time after 10 days of completing the treatment. DO NOT treat all cases of recurrent malaria as cases of RESISTANT malaria. In cases of proven P. falciparum recrudescence (recurrence of symptoms within 28 days of treatment), re-treat with Chloroquine + Pyrimethamine/Sulfadoxine and also administer primaquine single dose again.

Consider severe malaria in patients presenting with hyperpyrexia, anaemia, jaundice, altered behaviour, altered sensorium, convulsions, prostration, hypotension, breathlessness, oliguria etc. and refer them to higher centres immediately. In all such cases, consider P. falciparum malaria even if the QBC or peripheral smear reports show P. vivax malaria.

Treat all cases of complicated/severe malaria with PARENTERAL antimalarials. Do not use oral drugs, for their absorption may be erratic in the presence of severe illness. Also, DO NOT use mefloquine in severe malaria as it has a long half-life and acts slowly.

Decide on antimalarial drugs before starting treatment. Do not change the treatment in between unless warranted. Co-administration of chloroquine/quinine/mefloquine or quinine/mefloquine/ primaquine can have synergistic neuropsychiatric adverse effects.

Widal test may be positive (up to 1:320 dilution) in malaria and one should not start treatment for typhoid when MP test is positive unless the Widal titer is more than 1:640 or increases by four fold.

Report ALL positive as well as negative results of MP tests to Mangalore City Corporation (Telephone 105) on a weekly basis. Deaths should be reported IMMEDIATELY and in such cases, an unstained peripheral smear should be preserved for documentation.

Dosage and administration of antimalarial agents

ALL cases of fever should be given PRESUMPTIVE antimalaria treatment as per the table below:

Age (yrs.)

Dosage of CHLOROQUINE
(as base, single dose)

Dosage of PRIMAQUINE
(as early as possible)

Pyrimethamine 25 mg + Sulfadoxine 500 mg tab (Single Dose)

Day 1

Day 2

Day 3

P. falciparum Single dose (0.75mg/kg)

P. vivax/Mixed OD X 14 days (0.25mg/kg)

Presumptive Treatment For High Risk Areas

0-1 75 mg 75 mg 37.5 mg Nil Nil 1/4 tab.

1 - 4 150 mg 150 mg 75 mg 7.5 mg 2.5 mg 1/2 tab.

4 - 8 300 mg 300 mg 150 mg 15 mg 5 mg 1 tab.

8-14 450 mg 450 mg 225 mg 30 mg 10 mg 2 tabs.

>14 600 mg 600 mg 300 mg 45 mg 15 mg 3 tabs.

For P. vivax malaria: Chloroquine +Primaquine for 14 days

For uncomplicated P. falciparum malaria: Chloroquine+Pyrimeth/sulfadoxine*+Primaquine single dose

For uncomplicated mixed infections: Chloroquine+ Pyrimethamine/sulfadoxine* + Primaquine 14 days

*For patients allergic to sulfa, chose other; see below.

Combination Chemotherapy for P. falciparum malaria: In cases of uncomplicated P. falciparum infection, if the patient does not improve clinically and/or the parasite count does not reduce by >75% of pre-treatment levels after 48 hours, resistance should be considered and newer drugs may be needed. Also, non-immune patients who are suffering from P. falciparum malaria for the first time are more prone for complications and if such patients show any symptoms/signs of severe malaria, consider starting them on combination chemotherapy with newer drugs. All cases of complicated P. falciparum malaria should be treated with parenteral anti-malarial drugs. The following regimen can be used:

Chloroquine+ Sulfadoxine/pyrimethamine as above
Artemisinin Derivatives:
- Arteether: 3mg/kg IM OD for 3 days Plus Mefloquine as below
- Artesunate: 2.4mg/kg IV/IM loading followed by 1.2mg/kg at 12 and 24 hours and then 1.2mg/kg daily for 5 days or 2.4mg/kg once daily Plus Mefloquine as below
  Oral: 4mg/kg for 3 days OR 4mg/kg followed by 2mg/kg for 4 days Plus Mefloquine
  OR for 7 days (4mg/kg followed by 2mg/kg) with Clindamycin or Doxycycline as below
- Artemether: 3.2mg/kg loading; 1.6mg/kg/day for 3 days Plus Mefloquine as below
  Oral: 4mg/kg for 3 days Plus Mefloquine
Mefloquine: 15mg/kg followed 8-10 hours later by 10mg/kg
Quinine: (in combination with Tetracycline/Doxycycline OR Clindamycin as below)
- IV: 7 mg/kg over 30 min (or 20 mg/kg over 4 h, then 10 mg/kg over 4 h., every 8 hrs.
- IM: 20mg/kg stat, then 10mg/kg 8 hrly (max. 1800mg/d); start oral Quinine at the earliest and complete 7 days. Monitor blood glucose every 4 hrs. if patient has severe malaria or pregnancy
- Oral: 10mg of salt/kg q8h for 7 days
Tetracycline (4mg/kg qid) OR Doxycycline (3mg/kg OD) OR Clindamycin (10mg/kg bid) for 7 days

The choice of drugs would depend on age, pregnancy and allergy to sulfa.

Monitoring P. falciparum Malaria: 4 hourly blood glucose; 12 hourly hemoglobin, PCV, parasite count; 24 hourly S. bilirubin, S. creatinine.

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Dr. B.S. Kakkilaya's Malaria Web Site
Last Updated: April 14, 2006

B. S. Kakkilaya 2006-2008
malariasite.com 2006-2008

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