Indian Guidelines &
Protocols For The Treatment
Of Malaria
Dr. Lokesh Garg MD.
{MED.}
Santosh hopital Yamuna nagar
Introduction
Major public health problem of India
Around 1.5 million confirmed cases are reported
annually (NVBDCP)
50%...


Causative agent: intracellular plasmodium protozoa.



Species : P.falciparum , P.malariae , P.ovale , P.vivax.
(P.kno...


Malaria kills in one year what AIDS kills in
15 years. For every death due to HIV/AIDS
there are about 50 deaths due to...
Exo-erythrocytic (hepatic) Cycle:
Sporozoites infect liver cells and develop
into schizonts, which release merozoites
into...
Malaria Life Cycle
Oocyst
Sporozoites
Mosquito Salivary
Gland

Zygote

Exoerythrocytic
(hepatic) cycle

Gametocytes

Eryth...
The Malaria Transmission Cycle
Sites of Action for Antimalarial Drugs
TISSUE SCHIZONTOCIDES:
primaquine
pyrimethamine
prog...
Artemisinin derivatives
Dihydroartemisin

Ethyl Ether
Arteether
Qinghaosu
("ching-how-soo")

Methyl Ether
Artemether

Hemi...
 Artemisinin-based

combination therapy

(ACT) is an antimalarial combination
therapy with an artemisinin derivative as
o...
Clinical features
Fever -The cardinal symptom of malaria.
chills and rigors.
Headache
 myalgia,
Arthralgia
 anorexia
...
Why Early Diagnosis &
Treatment
Microscopy
Microscopy of stained thick and thin blood smears - gold standard
 The sensitivity is high.
 Detect malaria p...



Based on the detection of circulating parasite antigens
RDT - based on the detection of P falciparum histidine -rich
...
Treatment of P. Vivax Malaria
1. Chloroquine : - Drug of choice
25 mg/kg divided over three days i.e.10 mg/kg (600 mg ) on...
ACT drug of choice
Artemisinin Combination Therapy (ACT)
+
single dose primaquine (0.75 mg/kg or 45 mg ) on Day 2.
The ACT...
Other ACT can also be used Artemether + Lumefantrine
Artesunate + Amodiaquine
Oral artemisinin monotherapy is banned in In...
Short half-life; hence good for combination
 Rapid substantial reduction of the parasite biomass
 Rapid resolution of cl...


Uncomplicated Pf.
- Quinine - Drug for choice in first trimester.
- ACT is recommended in 2nd & 3rd trimester



P. vi...
 Treated

as falciparum malaria with ACT.

 Antirelapse

treatment with primaquine can be
given for 14 days




Impaired consciousness/coma
Repeated generalized convulsions



Renal failure (Serum Creatinine >3 mg/dl)



Jaun...


Metabolic acidosis



Circulatory collapse/shock (Systolic BP <80 mm Hg, <50
mm Hg in children)



Abnormal bleeding ...






Severe malaria is an emergency and treatment should be given
promptly. Parenteral artemisinin derivatives or quin...
Artemether : 3.2 mg/kg body weight i.m. given
on admission then 1.6 mg/kg body weight per day.

α−β Arteether: 150 mg dail...
Quinine: 20 mg quinine salt/kg body weight on admission
 (i.v. infusion in 5% dextrose/dextrose saline over a period of 4...
Patients receiving parenteral quinine should be
treated with
 oral quinine 10 mg/kg body weight three times a
day 4 days,...


First trimester of pregnancy parenteral quinine is the drug of choice.
- If quinine is not available Artemisinin deriva...


Doxycycline:
100 mg daily in adults and 1.5 mg/kg body weight for

children more than 8 years old.
Should be started ...


Mefloquine:
 5 mg/kg body weight (up to 250 mg) weekly
and should be administered two weeks before,
during and four we...
Blood

transfusion, IVDU , Organ transplantation

I.P.

- short ( no preerythrocytic stage )

C/F

& management - same ...
Santosh hospital ppt in malaria
Santosh hospital ppt in malaria
Santosh hospital ppt in malaria
Santosh hospital ppt in malaria
Santosh hospital ppt in malaria
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Santosh hospital ppt in malaria

  1. 1. Indian Guidelines & Protocols For The Treatment Of Malaria Dr. Lokesh Garg MD. {MED.} Santosh hopital Yamuna nagar
  2. 2. Introduction Major public health problem of India Around 1.5 million confirmed cases are reported annually (NVBDCP) 50% are due to Plasmodium falciparum. ( most severe form of disease )
  3. 3.  Causative agent: intracellular plasmodium protozoa.  Species : P.falciparum , P.malariae , P.ovale , P.vivax. (P.knowlesi -documented in malaysia , , indonesia,singapur,phillippines)  Transmission: Female anopheles mosquitoes. ( Also transmitted through blood transfusion ,use of contaminated needles, from pregnant women to fetus)
  4. 4.  Malaria kills in one year what AIDS kills in 15 years. For every death due to HIV/AIDS there are about 50 deaths due to malaria. To add to the problem is the increasing drug resistance to the established drug.
  5. 5. Exo-erythrocytic (hepatic) Cycle: Sporozoites infect liver cells and develop into schizonts, which release merozoites into the blood Sporozoites injected into human host during blood meal Parasites mature in mosquito midgut and migrate to salivary glands MOSQUITO Parasite undergoes sexual reproduction in the mosquito HUMAN Some merozoites differentiate into male or female gametocyctes Dormant liver stages (hypnozoites) of P. vivax and P. ovale Erythrocytic Cycle: Merozoites infect red blood cells to form schizonts
  6. 6. Malaria Life Cycle Oocyst Sporozoites Mosquito Salivary Gland Zygote Exoerythrocytic (hepatic) cycle Gametocytes Erythrocytic Cycle Hypnozoites
  7. 7. The Malaria Transmission Cycle Sites of Action for Antimalarial Drugs TISSUE SCHIZONTOCIDES: primaquine pyrimethamine proguanil tetracyclines MOSQUITO SPORONTOCIDES: primaquine pyrimethamine proguanil HUMAN GAMETOCYTOCIDES: primaquine BLOOD SCHIZONTOCIDES: chloroquine mefloquine quinine/quinidine tetracyclines halofantrine sulfadoxine pyrimethamine artemisinins
  8. 8. Artemisinin derivatives Dihydroartemisin Ethyl Ether Arteether Qinghaosu ("ching-how-soo") Methyl Ether Artemether Hemisuccinate Artesunate
  9. 9.  Artemisinin-based combination therapy (ACT) is an antimalarial combination therapy with an artemisinin derivative as one component of the combination given for at least 3 days.
  10. 10. Clinical features Fever -The cardinal symptom of malaria. chills and rigors. Headache  myalgia, Arthralgia  anorexia Nausea vomiting.
  11. 11. Why Early Diagnosis & Treatment
  12. 12. Microscopy Microscopy of stained thick and thin blood smears - gold standard  The sensitivity is high.  Detect malaria parasites at low densities. Helps to quantify the parasite load. Distinguish the various species of malaria parasite and their different stages.
  13. 13.   Based on the detection of circulating parasite antigens RDT - based on the detection of P falciparum histidine -rich protein-2 (PfHRP-2) ,does not detect the other 3 species.  For Vivax and Falciparum -Dipstick tests based on parasite lactate dehydrogenase are now available.  These tests have high sensitivity and specificity, require no special equipment or training, and produce results rapidly.  However, they remain positive for a week or more after the treatment and cure, and, in this situation, can yield false-positive results.
  14. 14. Treatment of P. Vivax Malaria 1. Chloroquine : - Drug of choice 25 mg/kg divided over three days i.e.10 mg/kg (600 mg ) on day 1, 10 mg/kg ( 600 mg ) on day 2 & 5 mg/kg on day 3. 2. Primaquine : 0.25 mg/kg 15 mg/day daily for 14 days. Primaquine is contraindicated in known G6PD deficient patients, infants and pregnant women.
  15. 15. ACT drug of choice Artemisinin Combination Therapy (ACT) + single dose primaquine (0.75 mg/kg or 45 mg ) on Day 2. The ACT recommended in the National Programme of India is Artesunate (4 mg/kg body weight) daily for 3 days & Sulfadoxine (25 mg/kg body weight) - pyrimethamine (1.25 mg/kg body weight) on Day 0.
  16. 16. Other ACT can also be used Artemether + Lumefantrine Artesunate + Amodiaquine Oral artemisinin monotherapy is banned in India Artemisinin derivatives must never be administered as monotherapy for uncomplicated malaria. These rapidly acting drugs, if used alone, can lead to development of drug resistance.
  17. 17. Short half-life; hence good for combination  Rapid substantial reduction of the parasite biomass  Rapid resolution of clinical symptoms  Effective action against multi-drug resistant P. falciparum  Reduction of gametocyte carriage  No documented parasite resistance yet  Few reported adverse effects. 
  18. 18.  Uncomplicated Pf. - Quinine - Drug for choice in first trimester. - ACT is recommended in 2nd & 3rd trimester  P. vivax malaria CQ drug choice in all trimester
  19. 19.  Treated as falciparum malaria with ACT.  Antirelapse treatment with primaquine can be given for 14 days
  20. 20.    Impaired consciousness/coma Repeated generalized convulsions  Renal failure (Serum Creatinine >3 mg/dl)  Jaundice (Serum Bilirubin >3 mg/dl)  Severe anaemia (Hb <5 g/dl)  Pulmonary oedema/acute respiratory distress syndrome  Hypoglycaemia (Plasma Glucose <40 mg/dl)
  21. 21.  Metabolic acidosis  Circulatory collapse/shock (Systolic BP <80 mm Hg, <50 mm Hg in children)  Abnormal bleeding and Disseminated intravascular coagulation (DIC)  Haemoglobinuria  Hyperpyrexia (Temperature >106o F or >42o C)  Hyperparasitaemia (>5% parasitized RBCs )
  22. 22.    Severe malaria is an emergency and treatment should be given promptly. Parenteral artemisinin derivatives or quinine should be used irrespective of chloroquine sensitivity. Artesunate: 2.4 mg/kg body weight i.v. or i.m. given on admission (time=0), then at 12 hours and 24 hours, then once a day (Till patient takes orally or for 7 days). Then full course of ACT for 3 days Other drugs used are arteether , artemether, quinine ( along with doxycycline/clindamycin)
  23. 23. Artemether : 3.2 mg/kg body weight i.m. given on admission then 1.6 mg/kg body weight per day. α−β Arteether: 150 mg daily i.m. for 3 days in adults only (not recommended for children).
  24. 24. Quinine: 20 mg quinine salt/kg body weight on admission  (i.v. infusion in 5% dextrose/dextrose saline over a period of 4 hours)  Maintenance dose of 10 mg/kg body weight 8 hourly  Infusion rate should not exceed 5 mg/kg body weight per hour.  Loading dose of 20 mg/kg body weight should not be given, if the patient has already received quinine..  NEVER GIVE BOLUS INJECTION OF QUININE.  If parenteral quinine therapy needs to be continued beyond  48 hours, dose should be reduced to 7 mg/kg body weight 8 hourly. 
  25. 25. Patients receiving parenteral quinine should be treated with  oral quinine 10 mg/kg body weight three times a day 4 days, along with doxycycline 3 mg/ kg body weight per day for 7 days.   (Doxycycline is contraindicated in pregnant women and children under 8 years of age; instead, clindamycin 10 mg/kg body weight 12 hourly for 7 days should be used).
  26. 26.  First trimester of pregnancy parenteral quinine is the drug of choice. - If quinine is not available Artemisinin derivatives may be given to save the life of mother  In second and third trimester. - Parenteral artemisinin derivatives are preferred.
  27. 27.  Doxycycline: 100 mg daily in adults and 1.5 mg/kg body weight for children more than 8 years old. Should be started 2 days before travel and continued for 4 weeks after leaving the malarious area.
  28. 28.  Mefloquine:  5 mg/kg body weight (up to 250 mg) weekly and should be administered two weeks before, during and four weeks after leaving the area.
  29. 29. Blood transfusion, IVDU , Organ transplantation I.P. - short ( no preerythrocytic stage ) C/F & management - same as for naturally acquired infection Primaquin is unnecessary ( no preerythrocytic stage so relapses do not occur.

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