Internal Medicine

0521779407-14 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:16

944 Malaria

management

What to Do First

■Evaluate blood smears to confirm diagnosis and parasite species.

■Consider hospitalization for all patients with falciparum malaria.

■Admit patients with severe disease to ICU (abnormal men-

tal status; >3% parasitemia; hematocrit <20%; hypoglycemia;

renal, cardiac, pulmonary, or hepatic dysfunction; DIC; prolonged

hyperthermia; severe vomiting or diarrhea) and treat with parenteral

therapy.

General Measures

■One negative blood smear does not rule out malaria; if initially neg-

ative, repeat thick blood smears every 12 h for 48 h.

■If uncertain about parasite species or drug sensitivity, treat for

chloroquine-resistant P. falciparum with quinine or quinidine.

■In severe disease, carefully monitor glucose, hemoglobin/

hematocrit, fluid, electrolyte, and acid-base balance; give prophy-

lactic anticonvulsants (phenobarbital) to unconscious patients; con-

sider exchange transfusion for severely ill patients with hyperpara-

siternia (>5–15%); avoid use of corticosteroids in cerebral malaria.

■Check G6PD level before prescribing primaquine.

specific therapy

Indication

■Positive blood smear or other diagnostic test; empiric treatment indi-

cated if clinical suspicion is high and diagnostic tests are pending

■Consult CDC for current recommendations: http://www.cdc.gov; malaria

hotlines 770-488-7788 (treatment) and 888-232-3228 (prophylaxis)

■Antimalarial drug doses can be expressed either in amounts of base

or salt; be specific when ordering medications.

■Uncomplicated Chloroquine-Sensitive Malaria

➣Chloroquine

➣PLUS Primaquine (for radical cure of P. vivax and P. ovale only)

■Severe Chloroquine-sensitive Malaria

➣Chloroquine

■Uncomplicated Chloroquine-Resistant Malaria

➣Quinine orally PLUS Doxycycline OR Tetracycline OR Clin-

damycin OR sulfadoxine-pyrimethamine (Fansidar)

➣OR Mefloquine (Larium)

➣OR Atovaquone/Proguanil (Malarone)