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					Treatment

Summary Approach

      Eliminate parasitemia and prevent recurrent disease
      Treatment should begin as soon as possible, especially in P falciparum, to avoid
       cerebral malaria, acute renal failure, acute gastroenteritis, pulmonary edema,
       extensive hemolysis, and splenic rupture
      Choice of treatment depends on the species and the likelihood of resistance to
       chloroquine or mefloquine, which can be inferred from the geographical region in
       which infection was acquired. This information and precise recommendations are
       available from the Centers for Disease Control and Prevention (CDC) and the World
       Health Organization (WHO), both of which produce numerous reports and guidelines
       about malaria, which are updated regularly. The treatment regimen should not be
       based on an agent that was used for prophylaxis (which presumably failed because of
       resistance or some other factor). If the species cannot be determined from available
       laboratory data, treatment should be aimed at P falciparum, and resistance to
       chloroquine should be assumed if the infection was acquired in an area where
       chloroquine resistance has been documented.

Chloroquine-sensitive Plasmodia:
      First choice for malaria caused by P ovale and P malariae, as well as sensitive strains
       of P vivax and P falciparum, is chloroquine, which is also recommended as a first-line
       treatment in pregnant women
      In P ovale and P vivax, this is followed by primaquine to eradicate the hypnozoites
       and avoid relapses

Chloroquine-resistant P vivax:
      Quinine, doxycycline, and primaquine or
      Atovaquone-proguanil and primaquine or
      Mefloquine and primaquine
      All three choices are recommended equally
      Quinine alone is recommended for the treatment of pregnant women

Chloroquine-resistant P falciparum:
      Atovaquone-proguanil or
      Artemether-lumefantrine or
      Quinine and either doxycycline or clindamycin (doxycycline preferred)
      All three choices are recommended equally
      Fourth choice is mefloquine
      Quinine and clindamycin are recommended for treatment in pregnant women
Severe malaria:
      The CDC recommends quinidine plus either doxycycline or clindamycin as the
       treatment of choice for all patients in the U.S. with severe malaria. Severe malaria is
       usually due to P falciparum
      Clindamycin is preferred for pregnant women and children younger than 8 years as
       tetracyclines should be avoided in these patient groups

Other therapies:
      Treatment recommendations are the same for patients with HIV
      A controversial procedure that may be effective as an adjunct to pharmacologic
       therapy is exchange transfusion therapy

Efficacy of therapies:
      Efficacy must be measured clinically
      After 48 hours of therapy, patients with drug-sensitive, uncomplicated malaria should
       show marked clinical improvement
      80% to 95% of malaria cases can be cured if treated early with the appropriate drugs
      By 96 hours patients should defervesce
      If parasitemia does not decrease by 75% in 48 hours, drug resistance should be
       assumed and treatment regimen changed

Medications

      Chloroquine
          ○ Indication
                 - Chloroquine is the first choice for treatment of mild to moderate
                    malaria caused by P ovale and P malariae, as well as sensitive strains
                    of P vivax and P falciparum
                 - It is also indicated for prophylaxis against malaria in regions where
                    there are no resistant strains
          ○ Dose information
                 - Dose conversion: 300 mg base = 500 mg salt
          ○ Treatment (Adult):
                 - Oral: 600 mg base immediately; followed by 300 mg at 6 hours, 24
                    hours, and 48 hours after first dose
                 - Total dose: 1500 mg over 3 days
                 - Dose refers to chloroquine base
      Primaquine
          ○ Indication
                 - Primaquine is for the follow-up treatment of malaria caused by P ovale
                    and P vivax (whether treating strains sensitive or resistant to
                    chloroquine) to eradicate the hypnozoites and avoid relapses
          ○ Dose information
                 - Dose conversion: 30 mg base = 52.6 mg salt
       ○ Treatment (Adult):
              - Oral: 30 mg once a day
              - Doses refer to primaquine base
              - Treatment course: 14 days
   Quinine
       ○ Indication
              - Quinine, in combination with doxycycline and primaquine, is indicated
                 for the treatment of mild to moderate infection due to chloroquine-
                 resistant P vivax
              - In combination with doxycyline or clindamycin, it is indicated for the
                 treatment of mild to moderate infection due to chlorquine-resistant P
                 falciparum
       ○ Dose information
              - Dose conversion: 542 mg base = 650 mg salt
       ○ Treatment (Adult):
              - Oral: 650 mg every 8 hours
              - Dose refers to quinine salt
              - Treatment course: 3 to 7 days (7 days if infection acquired in southeast
                 Asia)
   Doxycycline
       ○ Indication
              - Doxycyline, in combination with quinine and primaquine, is indicated
                 for the treatment of mild to moderate infection caused by chloroquine-
                 resistant P vivax
              - In combination with quinine, it is indicated for the treatment of mild to
                 moderate infection caused by chloroquine-resistant P falciparum
              - In combination with quinidine, it is indicated for the treatment of
                 severe malaria
              - Doxycyline is also indicated for prophylaxis in areas with malaria
                 caused by chloroquine- or mefloquine-resistant organisms
       ○ Treatment (Adult):
              - Oral or intravenous: 100 mg every 12 hours
              - Treatment course: 7 days
   Atovaquone-proguanil
       ○ Indication
              - Atovaquone-proguanil is indicated for the treatment of mild to
                 moderate infection caused by chloroquine-resistant P falciparum
              - Indicated, in combination with primaquine, for treatment of mild to
                 moderate infection caused by chloroquine-resistant P vivax
              - Also indicated for prophylaxis in areas with malaria caused by
                 chloroquine- or mefloquine-resistant organisms
       ○ Treatment (Adult):
              - 1000 mg atovaquone combined with 400 mg proguanil by mouth once
                 a day
              - Treatment course: 3 days
   Mefloquine
        ○ Indication
              - Mefloquine is indicated for the treatment of mild to moderate infection
                  due to chloroquine-resistant P vivax, in combination with primaquine
              - Mefloquine is indicated for the treatment of mild to moderate infection
                  due to chloroquine-resistant P falciparum
              - It is also indicated for prophylaxis in areas with malaria caused by
                  chloroquine-resistant organisms (unless mefloquine resistance has also
                  emerged)
        ○ Dose information
              - Dose conversion: 228 mg base = 250 mg salt
        ○ Treatment (Adult):
              - 750 mg by mouth immediately; followed by 500 mg 6 to 12 hours later
              - Total dose: 1250 mg
              - Dose refers to mefloquine salt
   Artemether-lumefantrine
        ○ Indication
              - Artemether-lumefantrine is indicated for the treatment for mild to
                  moderate infection caused by chloroquine-resistant P falciparum
        ○ Dose information
              - One tablet contains artemether 20 mg and lumefantrine 120 mg
        ○ Treatment (Adult):
              - 4 tablets initially, repeated 8 hours later, then 4 tablets twice daily for 2
                  days (total 6 doses, 24 tablets)
   Clindamycin
        ○ Indication
              - Clindamycin, in combination with quinine or quinidine, is indicated for
                  the treatment of chloroquine-resistant P falciparum
        ○ Treatment (Adult):
              - Oral: 20 mg/kg/d, given in divided doses every 8 hours
              - Intravenous: 10 mg/kg loading dose; followed by 5 mg/kg/dose every 8
                  hours
              - Treatment course: 7 days

				
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posted:8/16/2011
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