Tx of malaria

Question 1

First line tx of malaria

Answer 1

• Intravenous artesunate for severe falciparum malaria
• Use intravenous quinine if artesunate is not available
• Use quinine and clindamycin to treat uncomplicated P. falciparum
• Use chloroquine to treat P. vivax, P. ovale or P. malariae

Question 2

Artenusate for tx of severe malaria

Answer 2

• 2.4 mg/kg at 0, 12 and 24 hours, then daily thereafter.
• When the patient is well enough to take oral medication artesunate 2 mg/kg (or IM artesunate 2.4 mg/kg) once daily, plus clindamycin.

Question 3

Quinine for tx of severe malaria

Answer 3

• Quinine IV 20 mg/kg loading dose (no loading dose if patient already taking quinine or mefloquine) in 5% dextrose over 4 hours and then 10 mg/kg IV over 4 hours every 8 hours plus clindamycin IV 450 mg
  every 8 hours (max. dose quinine 1.4 g).
• When the patient is well enough to take oral medication she can be switched to oral quinine
  600 mg 3 times a day to complete 5–7 days and oral clindamycin 450 mg 3 times a day 7 days

Question 4

Side effects of quinine

Answer 4

Cinchonism: tinnitus, headache, nausea, diarrhoea, altered auditory acuity and blurred vision

Question 5

Recurrence of malaria

Answer 5

• Usually day 28–42
• 85 days with quinine
• 98 days with artesunate
• 63 days with artemether-lumefantrine
• 121 days with mefloquine
• Weekly screening by blood film until delivery allows these women to be detected positive before becoming symptomatic

Question 6

Complications of severe malaria infection - Hypoglycemia

Answer 6

• Commonly asymptomatic, although it may be associated with fetal bradycardia and other signs of fetal distress
• In the most severely ill women, it is associated with lactic acidosis and high mortality
• Abnormal behaviour, sweating and
  sudden loss of consciousness are the usual manifestations of quinine related hypoglycemia
• The hypoglycaemia of quinine is caused
  by hyperinsulinaemia and remains the most common and important adverse effect of this drug
• It may be profound, recurrent and intractable in pregnancy
• It may present late in the disease when the patient appears to be recovering

Question 7

Complications of severe malaria infection - Pulmonary oedema

Answer 7

• It may be present on admission or may develop suddenly and unexpectedly
• It may develop immediately after childbirth
• High mortality of over 50%
• Monitor the central venous pressure and urine output

Question 8

Complications of severe malaria infection - Anaemia

Answer 8

• Maternal morbidity
• Increased risk of postpartum haemorrhage
• Perinatal mortality
• May develop acute pulmonary oedema after separation of the placenta
• Transfuse slowly packed red cells
• Consider exchange transfusion

Question 9

Complications of severe malaria infection - Secondary infection

Answer 9

• Principally Gram-negative septicaemia

- Broad-spectrum antibiotics (such as ceftriaxone) should be started immediately