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Plasmodium
falciparum malaria is the cause of all the mortality and most of the morbidity in
malaria. It can present with atypical features, it can cause dramatic complications and to
add to the woes, treatment may be rendered difficult by resistance to antimalarial drugs.
Treatment of P. falciparum malaria therefore is different from that of other
types of malaria. It depends on the severity of infection, status of the host and drug
sensitivity pattern in the locality. In view of the seriousness of the problem and
synergistic toxicity of antimalarial drugs, the drugs should be properly chosen right at
the start of the treatment. Changing the drugs or adding of drugs half-way through the
treatment only complicates the issue and adds to the adverse effects of treatment.
Although blood schizonticidal drugs like
chloroquine are enough to give a radical cure of the falciparum infection, Primaquine
should be administered to all patients as a gametocytocidal drug to prevent the spread of
this potentially lethal infection. However, primaquine should not be used concurrently
with quinine and mefloquine and it is contraindicated in pregnancy and lactation.
In cases of severe P. falciparum
malaria, only parenteral drugs should be used. And in all such cases, it is safer to
presume drug resistance and start on drugs other than chloroquine, because waiting for a
response to chloroquine may prove costly for the patient.
In cases of resistant P. falciparum
malaria, it is better to use two antimalarial drugs. Various combinations have been tried,
but it is advisable to use one rapid acting drug and another slow acting drug in
combination.
In places where the QBC test is widely
used for diagnosis of malarial infection, it is better to get a thin smear examined for
assessing parasite count in all positive cases of P. falciparum malaria. This
simple test would help in assessing the severity of the infection, in monitoring response
to treatment, and in identifying cases of resistance.
Treatment of P. falciparum malaria - A
flow chart |
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Uncomplicated and chloroquine sensitive |
Complicated and chloroquine sensitive |
| Tab. Chloroquine + Primaquine single dose |
Inj. Chloroquine + Primaquine single dose |
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After 48 hours |
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Better; parasite count reduced by >75% |
Status quo/ worse; parasite count reduced by <75% |
Continue |
Consider resistance |
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Drugs for chloroquine resistant malaria |
| Uncomplicated and Chloroquine resistant |
Complicated and Chloroquine resistant |
Use any one of the following combinations:
1. Tab. Quinine + Tab. Pyrimethamine/ Sulfa.
2. Tab. Quinine + Tetracycline /doxycycline
3. Tab. Artesunate + Tab. Mefloquine
4.Tab. Mefloquine + Pyrimethamine/Sulpha. |
1. Inj.Quinine + Pyrimethamine/Sulphadoxine
2. Inj. Quinine + Tetracycline / Doxycycline
3. Inj. Artemether / Arteether / Artesunate + Mefloquine. |
Monitoring cases
of P. falciparum malaria
All cases of P. falciparum malaria, particularly in the
non-immune and high-risk population, should be monitored for complications. |
Clinical parameters: |
Vital signs, hydration, intake/output, level of sensorium, pallor,
jaundice. |
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Lab. parameters: |
4
hourly blood glucose (to detect hypoglycemia); 12 hourly hemoglobin, P.C.V. (to assess
hemolysis); 12 hourly parasite count (to assess response); 24 hourly S. creatinine, S.
bilirubin. |
Follow-up MP
tests
In all cases of P. falciparum malaria,
follow-up MP tests should be done on the 6th and 28th days after
treatment. The 6th day smear is done to assess clearance of parasitemia and 28th
day smear is done to identify recrudescence.
6th day smear: If the parasite
is sensitive to the drugs that have been used, then the parasitemia should clear within 7
days. However, gametocytes may be found on the smear and this does not require any
treatment; if primaquine has not been given, it can be given now. Persistence of ring
forms of the parasite indicates incomplete clearance and hence drug resistance. These
cases should be re-treated accordingly with other anti malarial drugs.
28th day smear: If the
parasite is not completely eradicated due to partial resistance, then the 28th
day smear will be positive. All such cases should be re-treated with other antimalarial
drugs. Primaquine should be re-administered in these cases to destroy freshly formed
gametocytes. The National Malaria Eradication Programme in India recommends repeat smears
on 6-7th, 14th, 21st, and 28th days of
treatment to identify resistance and recrudescence.
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