Dr.Karwa - clinical and therapeutics of malaria 4 q Flashcards
Signs and symptoms of malaria
Clinical symptoms: fever, HA, weakness, Rigors, Night sweats, insomnia, arthralgias, GI distress, neurological complications
Lab findings: anemia, hyponatermia, increased creatinine, thrombocytopenia
Diagnosis
For Diagnosis must complete a thick and thin smear blood test
Mosquito avoidance measures to prevent malaria
sleep under mosquito nets
stay in enclosed air conditioned rooms
use mosquito coils in living spaces
Mosquito repellant and treated clothing
Prophylaxis selections depend on region traveling to
All malaria-endemic regions
What are options and when do they need to be started and if any what are patient specific things to consider
Atovaquone/proguanil
- Begin 1-2 days before leave and continue for 7 days after leaving endemic area (avoid in CrCl <30, prego or breast feeding)
Doxycycline
- Begin 1-2 days before departure and continue for 4 weeks after leaving malaria endemic areas
WEAR SUNSCREEN
Tafenoquine
- Begin 3 days before departure and continue for 1 week after leaving malaria endemic areas
-MUST GET G6PD deficiency testing done first
Prophylaxis selections depend on region traveling to
Regions with chloroquine sensitive malaria
What are options and when do they need to be started and if any what are patient specific things to consider
Chloroquine
Hydroxychloroquine
Both same
Begin 1-2 weeks before departure and continue for 4 weeks after leaving malaria endemic areas
AE: blurred vision, GI, HA, insomnia
Prophylaxis selections depend on region traveling to
Regions primarily with P.Vivax
What are options and when do they need to be started and if any what are patient specific things to consider
Primaquine
- BEGIN 1-2 days before departure and continue for 7 days after leaving malaria endemic areas
- MUST GET G6PD testing done first
Prophylaxis selections depend on region traveling to
Regions with mefloquine-sensitive malaria
What are options and when do they need to be started and if any what are patient specific things to consider
Mefloquine
- Begin greater than or equal to 2 weeks before departure and continue for 4 weeks after leaving malaria endemic areas
- CANNOT GIVE TO ANYONE WITH HISTORY OF CNS DISORDER LIKE DEPRESSION AND ANXIETY
When to consider if patient has malaria and ehat are symptom onset
When patient has fever AND they have traveled to a malaria endemic region before fever onset
Onset: typically 2-4 weeks after mosquito bite
Severe malaria
Patient must have at least one of the following to be considered severe
-Impaired consciousness/coma
-Hemoglobin < 7 g/dL
-Acute kidney injury
-Acute respiratory distress syndrome (ARDS)
-Circulatory collapse/shock
-Acidosis
-Disseminated intravascular coagulation
-Parasite density of ≥ 5%
Typically caused
by P. falciparum
TREATMENT OPTIONS FOR UNCOMPLICATED
MALARIA
Presence of chloroquine resistance or unknown resistance
1.Artemether–lumefantrine
(Coartem)*
2.Atovaquone-proguanil
(Malarone)
3.Quinine
sulfate
PLUS
doxycycline,
tetracycline,
or
clindamycin
TREATMENT OPTIONS FOR UNCOMPLICATED
MALARIA
Presence of chloroquine resistance, no mefloquine resistance, or unknown resistance
Mefloquine
- Not for patient with history of CNS disorders
ANTI-RELAPSE TREATMENT
For P. Vivax and P. ovale infections
Primaquine
phosphate
OR
Tafenoquine
(Krintafel)
Both need G6PD deficiency testing
TREATMENT OF UNCOMPLICATED MALARIA:
P. FALCIPARUM OR UNKNOWN SPECIES
P. Falciparum or unknown
species acquired in area
with chloroquine resistance
Preferred:
* Artemether-lumefantrine
Alternatives:
* Atovaquone-proguanil
* Quinine PLUS tetracycline, doxycycline, or clindamycin
* Mefloquine (if no other options and no regional mefloquine
resistance)
TREATMENT OF UNCOMPLICATED MALARIA:
P. FALCIPARUM OR UNKNOWN SPECIES
P. Falciparum or unknown
species acquired in area
with NO chloroquine
resistance
Preferred:
* Chloroquine
* Hydroxychloroquine
Alternatives: any options used for treatment of chloroquine-
resistant infections
TREATMENT OF UNCOMPLICATED MALARIA:
P. OVALE OR P.VIVAX
P. ovale or P.
vivax acquired
in area with
chloroquine
resistance
Preferred:
* Artemether-lumefantrine
Alternatives:
* Atovaquone-proguanil
* Quinine PLUS tetracycline, doxycycline, or clindamycin
* Mefloquine (if no other options)
PLUS anti-relapse treatment (must do G6PD testing first)
* Primaquine
TREATMENT OF UNCOMPLICATED MALARIA:
P. OVALE OR P.VIVAX
P. ovale or P.
vivax acquired
in area with
no
chloroquine
resistance
Preferred:
* Chloroquine
* Hydroxychloroquine
Alternatives: any options used for treatment of chloroquine-resistant infections
PLUS anti-relapse treatment (must do G6PD testing first)
* Primaquine
* Tafenoquine (can only be used if received chloroquine for treatment)
TREATMENT OF UNCOMPLICATED MALARIA:
P. KNOWLESI OR P. MALARIAE
P. knowlesi or P. malariae
acquired in any area
Preferred:
* Chloroquine
* Hydroxychloroquine
Alternatives:
* Artemether-lumefantrine
* Atovaquone-proguanil
* Quinine PLUS tetracycline,
doxycycline, or clindamycin
* Mefloquine (if no other options)
Treatment of Severe malaria
IV artesunate
- Continue treatment until parasite density ≤ 1% (up to 7 days)
After finishing, transition to one of the following oral treatment:*
-Artemether-lumefantrine (preferred)
-Atovaquone-proguanil
-Quinine PLUS doxycycline or clindamycin
- Mefloquine
AM is a 19 yo male (he/him) and just returned from
his 3-week trip to Kenya where he took doxycycline
malaria chemoprophylaxis. He reports that he missed
a few doses and now presents with fever, chills,
malaise, and headache. He reports experiencing some
nausea and diarrhea.
Upon further examination he is found to have SCr of
1.5. The blood smear shows infection with P.
falciparum and parasitemia of 6%.
Based on the provided information does AM have
uncomplicated or severe malaria?
A. Uncomplicated malaria
B. Severe malaria
B
Given that we know AM has severe malaria, what is the
preferred treatment option at this time?
A. Artemether-lumefantrine 4 tablets PO once then 4 tablets
PO 8 hrs later then 4 tablets PO BID for 2 days
B. Mefloquine 750 mg salt PO once then 500 mg salt PO 6-12
hrs after the 1st dose
C. Artesunate 2.4 mg/kg IV at 0, 12, and 24 hrs then 2.4
mg/kg IV daily for up to 7 days
D. Quinine 650 mg salt PO TID x 3 days plus doxycycline 100
mg PO BID x 7 days
C
AM is clinically improving and has now received 3 days of IV
artesunate. The most recent blood stain demonstrated parasitemia
of 0.5%. What should the patient be treated with now?
A. Continue artesunate 2.4 mg/kg IV daily for a total of 7 days
B. Artemether-lumefantrine 4 tablets PO once then 4 tablets PO 8
hrs later then 4 tablets PO BID for 2 days PLUS primaquine
52.6 mg salt PO daily for 14 days
C. Chloroquine 1,000 mg salt PO once and 500 mg salt PO at 6,
24, 48 hrs after the 1 st dose
D. Artemether-lumefantrine 4 tablets PO once then 4 tablets PO 8
hrs later then 4 tablets PO BID for 2 days
D
