Malaria


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also:


      Background to condition: 

      Malaria is caused by Plasmodium parasites transmitted by mosquitoes. The five species that infect humans are P. falciparum, P. vivax, P. ovale, P. malariae, andP. knowlesi.

      • Severe malaria is largely caused by P. falciparum, though children with vivax and knowlesi malaria can also present seriously ill.
      • Liver hypnozoite eradication eliminates thePlasmodium forms that lie dormant in the liver that can cause relapse of illness months to years later. Only P. vivax and P. ovale produce hyponozoite forms. Those infected with P. vivax, P. ovale, or an unknown species must be treated with a course of primaquine to prevent relapse.

      Caution: Young children, especially those <5 years of age, are particularly prone to rapid deterioration and experience higher rates of severe and cerebral malaria than adults.

      Assessment: 

      Who should be assessed

      Any patient with a fever who has returned from an endemic malaria region (See CDCfor more information) in the previous 12 months should be assessed for malaria (even if prophylaxis was taken).

      History

      Full history with particular attention to

      • Travel history, including location, places of transit, urban vs. rural
      • Whether malaria prophylaxis was taken and, if so, which drug and compliance
      • Prior empiric treatment for malaria 

      Physical examination

      Full examination with particular attention to

      • clinical features of severe malaria
      • hepatosplenomegaly
      • jaundice
      • severe pallor
      • respiratory distress 

      Investigations 

      Definitive diagnosis

      • Thick and thin film - thick film is used to confirm the presence of parasites and percentage of erythrocytes containing parasites, thin film is used to identifyPlasmodium species
      • Malaria antigen/ICT - detects P. falciparum with >90% sensitivity, but is insensitive for other species or when there is a low level of parasitaemia.
      • Both tests are required: 1 ml blood in EDTA tube is sufficient for both 

      Note: A single negative film or antigen does not exclude malaria - thick and thin films should be repeated with fever spikes until positive test or 3 negative films. 

      Other investigations

      Consider (depending on likelihood of malaria and severity)

      • FBC, U+E, LFT
      • Blood glucose
      • Blood cultures
      • Blood gas
      • Coagulation profile
      • Group and hold
      • Sickle status
      • CXR

      Acute management: 

      The most important decision is whether the child has severe or uncomplicated malaria

      • Initial management should be based on clinical and laboratory parameters and the malaria species
      • In an unwell child assume falciparum is present as mixed infection is relatively common 

      Uncomplicated malaria

      In selected cases, outpatient management may be suitable. Otherwise, admit for observation and initiation of treatment. 

      Antimalarial treatment

      Clinical diagnosis and species

      Paediatric drug and dosing

      Comment

      Uncomplicated malaria

      P. falciparum or unidentified species

      Treatment of choice: 
      Artemether-lumefantrine (Riamet®, Coartem®)
      1 tablet = 20mg artemether/120mg lumefantrine
      5-14kg: 1 tablet
      15-24kg: 2 tablets
      25-34kg: 3 tablets
      >34kg: 4 tablets (adult dose)
      Orally with fatty food, full-fat milk, or breastmilk
      At 0, 8, 24, 36, 48, and 60 hours

      Alternative treatment (2nd choice):
      Atovaquone-proguanil (Malarone®)
      Adult tab: 250mg atovaquone/100mg proguanil
      Paediatric tab: 62.5mg atovaquone/25mg proguanil
      5-8kg: 2 paediatric tablet
      9-10kg: 3 paediatric tablet
      11-20kg: 1 adult tablet
      21-30kg: 2 adult tablets
      31-40kg: 3 adult tablets
      >40kg: 4 adult tablets (adult dose)
      Orally with fatty food, full-fat milk, or breastmilk
      Once daily x 3 days 

      Alternative treatment (3rd choice):
      Quinine AND clindamycin 
      Quinine sulphate
      1 tablet = 300mg salt
      (10mg/kg salt = 8.3mg/kg base)
      10mg salt/kg (up to 600mg) orally 8 hourly x 7 days

      PLUS 
      Clindamycin 5mg/kg (up to 300mg) orally 8 hourly x 7 days 
      See also primaquine to eradicate liver hypnozoites if species of Plasmodium is unknown














      Should not be used if atovaquone-proguanil has been taken as prophylaxis 




       








      Can be used even if mefloquine has been taken as prophylaxis

      Uncomplicated malaria

      P. vivax, P. ovale, P. malariae, and P. knowlesi

       

      All regions except if suspected chloroquine-resistant P. vivax (see below)

      Chloroquine 1 tablet = 155mg base = 250mg salt
      Hydroxychloroquine 1 tablet = 155mg base = 200mg salt
      10mg base/kg (up to 620mg) orally at 0 hours, then
      5mg base/kg up (to 310mg) at 6, 24, and 48 hours
      Total dose 25mg base/kg 

      OR  

      Artemether-lumefantrine (Riamet®, Coartem®)
      As above for uncomplicated P. falciparum
      See also primaquine to eradicate liver hypnozoites if species of Plasmodium is P. vivax or P. ovale

      Chloroquine is available in Australia through Special Access Scheme.

      Hydroxycholoroquine or artemether-lumefantrine are alternatives.

      Uncomplicated malaria 
      P. vivax

       

      Known chloroquine-resistant P. vivax regions ( CDC)

      Artemether-lumefantrine (Riamet®, Coartem®)
      As above for uncomplicated P. falciparum 


       See also primaquine to eradicate liver hypnozoites

       

       

                           

       

      Severe malaria

      Severe malaria is a medical emergency. 

      The presence of one or more of the following clinical or laboratory features classifies a patient as having severe malaria.

      Clinical features:

      • impaired consciousness or coma (cerebral malaria)
      • unable to sit up without assistance
      • vomiting or failure to feed
      • seizures
      • respiratory distress
      • shock/severe dehydration
      • haemoglobinuria
      • spontaneous bleeding (e.g. epistaxis, gum bleeding)
      • oliguria

      Laboratory features:

      • hypoglycaemia (blood glucose <2.2 mmol/l)
      • metabolic acidosis (plasma bicarbonate <15 mmol/l)
      • severe normocytic anaemia (Hb <70g/L)
      • hyperparasitaemia (>2%, though low peripheral parasitaemia is possible in cerebral malaria)
      • hyperlactataemia
      • renal impairment

      Initial treatment considerations

      • ABC: Caution with treating fluid balance/shock as vulnerable to fluid overload with cerebral and pulmonary oedema
      • Anti-malarial therapy - start intravenous anti-malarial medication urgently ( see table)
      • Hypoglycemia - can be exacerbated by intravenous quinine, follow Hypoglycaemia guidelines and ensure ongoing dextrose if requiring maintenance IV fluids
      • Address other complications including:
        • Seizures - treat as per 
        • Metabolic acidosis
        • Severe anaemia
        • Acute pulmonary oedema
        • Acute renal failure
        • Spontaneous bleeding or coagulopathy 
         

      Antimalarial treatment

      Diagnosis and species

      Paediatric drug and dosing

      Comment

      Severe malaria 
      Any (or mixed) Plasmodium species
      OR
      Inability to tolerate oral therapy

       

       

       

       

       

       

      Treatment of choice: 
      Artesunate 2.4mg/kg IV (bolus dose over 1-2 minutes) on admission
      Repeat at 12 hours and 24 hours, then once daily until oral therapy tolerated (see below)

      Available through Special Access Scheme

       

       

      Alternative treatment (if artesunate not available):  

      Quinine dihydrochloride
      Loading dose: 20mg/kg IV over 4 hours, then:
      Maintenance dose: 10mg/kg IV over 4 hours,
      8 hourly, starting 8 hours after starting loading dose, until the patient is able to tolerate oral

      Requiresslow infusion and cardiac monitoring (lethal hypotension possible if given rapidly) 

      Quinine may exacerbatehypoglycaemia  

      Loading dose of quinine is not required if patient has received

      • 3 or more doses of quinine or quinidine in the previous 48 hours
      • mefloquine prophylaxis in the previous 24 hours
      • mefloquine treatment dose within the previous 3 days
       

      When patient is able to tolerate oral therapy:

      Artemether-lumefantrine (Riamet®, Coartem®) - full course of 6 doses
      1 tablet = 20mg artemether/120mg lumefantrine
      5-14kg: 1 tablet
      15-24kg: 2 tablets
      25-34kg: 3 tablets
      >34kg: 4 tablets (adult dose)
      Orally with fatty food, full-fat milk, or breastmilk
      At 0, 8, 24, 36, 48, and 60 hours

      Discuss alternatives with local Infectious Disease Unit if Artemether-lumefantrine not available

       

      Primaquine for liver hypnozoite eradication

      All cases of P. vivax,P. ovale or unknown species should have liver hypnozoite eradication treatment.

      All patients should undergo G6PD deficiency screening prior to the administration of primaquine. If deficient, seek expert advice.

       

      Species

      Primaquine dose

      P. vivax (regardless of geographic region)

      0.5mg/kg (up to 30mg) orally daily (or divided 12 hourly if nausea) with food x 14 days

      P. ovale

      0.25mg/kg (up to 15mg) orally daily with food x 14 days

      Species unknown

      0.5mg/kg (up to 30mg) orally daily (or divided 12 hourly if nausea) with food x 14 days    

      Mild G6PD deficiency Seek expert advice
      0.75mg/kg (up to 45mg) orally weekly for 8 weeks

       

        Ongoing management for inpatients

      • Regular (6 to 12 hourly) finger prick glucose if severe malaria and/or on quinine
      • Daily thick malaria blood film for parasite count until negative
      • Monitor Hb and blood glucose
      • G6PD screening if primaquine indicated (P. vivax,P. ovale, or if species is unknown)
      • Consider discharge when afebrile for 24 hours, able to tolerate oral medications, and decreasing parasite counts 

      Consider consultation with local paediatric team:

      • Any child with suspected malaria 

      When to consider transfer to tertiary centre:

      • Any child with features of severe malaria
      • Child requiring care beyond the comfort level of the hospital

        For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

      Last updated August 2012