Malaria, severe

B50.0/B50.8

*Notifiable medical condition.

See the PHC STGs and EML Section: Malaria, severe/complicated.

DESCRIPTION

P. falciparum malaria with one or more of the following features:

  • severe general body weakness (prostration)
  • abnormal bleeding (e.g epistaxis)
  • impaired consciousness
  • convulsions
  • renal dysfunction
  • heavy parasitaemia (≥5%)
  • repeated vomiting
  • ARDS
  • severe diarrhoea
  • shock
  • severe anaemia (Hb <6 g/dL)
  • hypoglycaemia
  • haemoglobinuria
  • clinical jaundice
  • acidosis (plasma bicarb <15 mmol/L)

GENERAL MEASURES

Maintain hydration but avoid excessive fluid administration as this could contribute to the development of ARDS (especially in pregnancy).

Transfuse if haemoglobin <6 g/dL.

There is no convincing evidence of benefit for the use of exchange transfusion.

MEDICINE TREATMENT

Intravenous therapy:

The preferred agent is parenteral artesunate:

  • Artesunate IV, 2.4 mg/kg at 0, 12 and 24 hours; then daily until patient is able to tolerate oral therapy.
    • Administer at least 3 IV doses before switching to oral artemether/lumefantrine.

LoEI [22]

If parenteral artesunate is not available:

  • Quinine, IV (1 mL = 300 mg quinine salt).
    • Loading dose: 20 mg/kg in dextrose 5% administered over 4 hours.
    • Maintenance dose: 8 hours after start of the loading dose, give 10 mg/kg in dextrose 5% over 4 hours repeated every 8 hours until there is clinical improvement and the patient can take oral therapy.
    • Monitor for hypoglycaemia and dysrhythmias at least 4 hourly.
    • If there is significant renal failure increase dose interval to 12 hourly after 48 hours.

Follow intravenous therapy with oral therapy:

  • Artemether/lumefantrine 20/120 mg, oral, 4 tablets/dose with fat-containing food or full cream milk to ensure adequate absorption.
    • Give the first dose immediately.
    • Give the second dose 8 hours later.
    • Then 12 hourly for another 2 days. (Total number of doses in 3 days = 6; i.e. 24 tablets).

Monitor treatment response with regular blood smears.

An increase in parasitaemia may occur within 24 hours due to release of sequestrated parasites, but a reduction should be seen after 48 hours.

Note: Gametocytes may appear after this stage – this does NOT mean failure of therapy as gametocytes may persist for up to 2 weeks after successful therapy.

Only the reappearance of or failure to clear trophozoites means failure.

Consider concomitant bacteraemia in patients with severe malaria, especially if they have neutrophilia.

REFERRAL

Patient in need of ventilation or dialysis if these are unavailable on site.