WHO Guidelines for the Management of Malaria

Recommendations for Parasitological diagnosis:

Recommendation	Level of Evidence
In areas of low to moderate transmission, prompt parasitological confirmation of the diagnosis is recommended before treatment is started.	E
In areas of high stable malaria transmission, children under 5 years should be treated on the basis of clinical diagnosis. In older children and adults including pregnant females, a parasitological diagnosis is recommended before treatment is started	E
In all suspected cases of severe malaria, a parasitological confirmation of the diagnosis of malaria is recommended. In absence or delay in diagnosis, patients should be treated on clinical grounds.	E

 

Treatment of Uncomplicated P. Falciparum Malaria:

To counter the threat of resistance of P. Falciparum to monotherapies, and to improve treatment outcome, combination of antimalarials are now recommended.

Recommendation	Level of evidence
The treatment of choice for uncomplicated falciparum malaria is a combination of two or more antimalarials with different mechanisms of action	S, T, O
Artemisinin-based combination therapies (ACTs) are the recommended treatments for uncomplicated falciparum malaria	S
The following ACTs are currently recommended: Artemether+Lumefantrine, Artesunate+Amodiaquine, Artesunate+Mefloquine,                    Artesunate+Sulfadoxine-pyrimethamine	S, T, O
The choice of ACT in a country or region will be based on the level of resistance of the partner medicine in the combination: - in areas of multidrug resistance (SouthEast Asia), Artesunate+Mefloquine or Artemether+Lumefantrine - in Africa, Artemether+Lumefantrine, Artesunate+Amodiaquine,	E      S
The artemisinin derivative components of the combination must be given for at least 3 days for an optimum effect	S
Artemether+Lumefantrine ahould be used with a 6-dose regimen	T, E
Amodiaquine+Sulfadoxine-Pyrimethamine may be considered as an interim option where ACTs cannot be made available	E

If malaria is suspected and the decision to treat is made, then a full effective treatment is required, whether or not the diagnosis is confirmed by a test.

Recommendations on treatment approaches that should be avoided: 

Recommendation	Level of evidence
Partial treatment should not be given even when the patients are considered to be semi-immune or the diagnosis is uncertain.	E
The Artemisinin and the partner medicines of ACTs should not be available as monotherapies	E

Recommendation for Treatment Failure Management:

Failure within 14 days:

- Must be confirmed Parasitologically

- Should be treated with second line drugs

Failure after 14 days:

- Can be treated with the first line ACTs, except when initially treated with Mefloquine.

- Parasitological confirmation is desirable, but not a pre-condition.

Recommended Second-line antimalarial treatments:

- Alternative ACT known to be effective in the region

- Artesunate + Doxycycline/ Tetracycline/ Clindamycin

- Quinine + Doxycycline/ Tetracycline/ Clindamycin

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Solution to Quiz 6:

Answer: This patient was diagnosed to have a Descending thoracic Aortic aneurysm, just distal to the origin of Subclavian Artery.

On enquiry, he gave a history of upper back pain since last 6 months which he kept ignoring as muscular back pain.

As the aneurysm kept increasing in size he started getting compression of surrounding structures and hence the symptoms of Hoarseness of voice and Dysphagia.

The giddiness that he had was possibly due to increase in dissection and hypotension associated.

I’ll be discussing more about this case including the management principles in my new blog ‘Interesting Cases’ http://icucases.blogspot.com/

 

 

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QUIZ 6:

A 54 year old male patient,

known Hypertensive, Ischaemic heart disease, had undergone CAG – PTCA to LAD about 8 mnths back.

Now presents with

H/o Fever – low grade, on and off for last 6 mnths, being treated on out patient basis with multiple antibiotics;

H/o 1 episode of giddiness/ black-out about 2 months back;

H/o hoarseness of voice since last 3 weeks, IDL done: suggestive of Left vocal cord palsy; followed by

H/o dysphagia, to both solids and liquids, sudden in onset, since today morning.

What is your diagnosis?

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