malaria organism-specific therapy

7/30/2019 Malaria Organism-Specific Therapy

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Malaria Organism-Specific Therapy

Author: Joseph U Becker, MD; Chief Editor: Thomas E Herchline, MDUpdated: Jun 16, 2011

Specific Organisms and Therapeutic Regimens

All efforts should be made to confirm the diagnosis of malaria and to identify the species. Diagnosis isgenerally via Giemsa-stained thick and thin peripheral blood smears. Multiple other antibody-basedrapid diagnostic tests (RDTs) are also available. Complications ofPlasmodium falciparum infectionmay include impaired consciousness, seizures, severe anemia, renal failure, pulmonary edema oracute respiratory distress syndrome (ARDS), refractory hypotension, and disseminated intravascularcoagulation (DIC).[1, 2, 3]

The choice of therapeutic regimen is dependent on regional resistance patterns, the most likelyspecies involved, and the clinical condition of the patients, as well as on complicating factors such asaltered mental state and pregnancy.

If treatment must be initiated before the species is known, treat forP falciparum

P falciparum should be presumed to be chloroquine resistant, except in a few areas of CentralAmerica and the Middle East

Primaquine should be given ifPlasmodium vivaxorPlasmodium ovale is likely

Resistance patterns

Chloroquine-resistant P falciparum[1] :

Eastern Hemisphere: All of sub-Saharan Africa, Saudi Arabia, Yemen, Iran, Pakistan, Afghanistan,China, Nepal, and all of Southeast Asia

Western Hemisphere: Panama, Haiti, Brazil, Peru, Bolivia, Colombia, Venezuela, Ecuador, FrenchGuiana, Guyana, and Suriname

Chloroquine-sensitive P falciparum[1] :

Eastern Hemisphere: Turkey, Iraq, Syria, Georgia, Azerbaijan, Tajikistan, Turkmenistan, and

Kyrgyzstan Western Hemisphere: Argentina, Paraguay, Mexico, Guatemala, Costa Rica, Honduras, Nicaragua,

El Salvador, and Dominican RepublicMefloquine-resistant P falciparum[1] :

Southeast Asia: Regions of Vietnam, Laos, Thailand, Burma, and CambodiaChloroquine-resistant P vivax[1] :

Papua New Guinea and Indonesia

Uncomplicated P falciparum infection

Artemether-lumefantrine 20/120 mg tablet(s) PO in weight-based dosing (> 35 kg, 4 tablets/dose; 25-35 kg, 3 tablets/dose; 15-25 kg, 2 tablets/dose; 5-15 kg, 1 tablet/dose) for 6 doses, with dose 2 given8h after initial dose and remaining doses given BID for 2d or

Atovaquone-proguanil 250/100 mg adult tablet(s) or 62.5/25 mg pediatric tablets PO in weight-baseddosing (adults, 4 adult tablets; 31-40 kg, 3 adult tablets; 21-30 kg, 2 adult tablets; 11-20 kg, 1 adulttablet; 9-10 kg, 3 pediatric tablets; 5-8 kg, 2 pediatric tablets) q24h for 3d or

Quinine 650 mg PO TID for 3d (7d if malaria was acquired in southern Asia) plus doxycycline 100mg PO BID for 7d or

Mefloquine 750 mg PO as initial dose, then 500 mg PO 6-12h later (not recommended for malariaacquired in Southeast Asia)[1, 3]

Uncomplicated Plasmodium malariae, Plasmodium knowlesi, or chloroquine-sensitive Pfalciparum infection

Chloroquine phosphate 1000 mg (10 mg/kg base) PO as initial dose, then 300 mg (5 mg/kg) at 6h,24h, and 48h or

Hydroxychloroquine 800 mg PO as initial dose, then 400 mg PO at 6h, 24h, and 48h [1, 3]

Uncomplicated P vivax or P ovale infection, expected to be chloroquine-susceptible


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Chloroquine phosphate 1000 mg (10 mg/kg base) PO as initial dose, then 300 mg (5 mg/kg) at 6h,24h, and 48h plus primaquine 30 mg (0.5 mg/kg base) PO q24h for 14d or

Hydroxychloroquine 800 mg PO as initial dose, then 400 mg PO at 6h, 24h, and 48h plus primaquine30 mg (0.5 mg/kg base) PO q24h for 14d [1, 3]

Uncomplicated P vivax infection, expected to be chloroquine-resistant

Quinine 650 mg PO TID for 3d (7d if malaria was acquired in southern Asia) plus doxycycline 100mg PO BID for 7d plus primaquine 30 mg (0.5 mg/kg base) PO q24h for 14d or

Atovaquone-proguanil 1000/400 mg PO q24h for 3d (pediatric dosing as for uncomplicated Pfalciparuminfection) plus primaquine 30 mg (0.5 mg/kg base) PO q24h for 14d or

Mefloquine 750 mg PO as initial dose, then 500 mg PO 6-12h laterplus primaquine 30 mg (0.5mg/kg base) PO q24h for 14d or

Amodiaquine 10 mg/kg PO q24h for 3d (not available in the United States) plus primaquine 30 mg(0.5 mg/kg base) PO q24h for 14d[1, 3]

Complicated malaria

Preferred treatment, United States:

Quinidine gluconate 10 mg/kg loading dose over 1-2h, then 1.2 mg/kg/h for at least 24h

Once parasitemia is < 1% and patient can take oral medication, switch to quinine 650 mg PO TID tocomplete 3-d course (7-d course if malaria was acquired in southern Asia)

In addition, give doxycycline 100 mg IV or PO BID for 7d; for pregnant women, instead ofdoxycycline, give clindamycin 20 mg base/kg/day PO divided TID for 7d

Investigational treatment, United States (available in many countries):

Artesunate 2.4 mg/kg IV or IM given on admission (time = 0), then at 12h and 24h, then daily plus

Atovaquone-proguanil 1000/400 mg PO q24h for 3d (pediatric dosing as for uncomplicated Pfalciparuminfection) or doxycycline 100 mg IV or PO BID for 7d or clindamycin 20 mg base/kg/dayPO divided TID for 7d or mefloquine 750 mg PO as initial dose, then 500 mg PO 6-12h later[3]

Chemoprophylaxis options

Atovaquone-proguanil[3] :

Atovaquone-proguanil 1 tablet/day PO can be used as prophylaxis in all areas Begin 1-2d before travel to malarial areas; discontinue 7d after departure from malarial areas

Not recommended for prophylaxis if creatinine clearance < 30 mL/min

Atovaquone-proguanil should be taken with food or a milky drinkChloroquine phosphate[3] :

Chloroquine phosphate 300 mg base (500 mg salt) PO once weekly should be used as prophylaxisonly in areas with chloroquine-sensitive malaria

Begin 1-2wk before travel to malarial areas; discontinue 4wk after departure from malarial areasDoxycycline[3] :

Doxycycline 100 mg/day PO can be used as prophylaxis in all areas

Begin 1-2d before travel to malarial areas; discontinue 4wk after departure from malarial areas

Contraindicated in children < 8y and in pregnant women Significant risk for photosensitivity

Mefloquine[3] :

Mefloquine 250 mg PO once weekly can be used as prophylaxis in areas with mefloquine-sensitivemalaria

Begin 1-2wk before travel to malarial areas; discontinue 4wk after departure from malarial areas

Contraindicated in persons with active depression, generalized anxiety disorder, psychosis,schizophrenia, or seizures

Not recommended for persons with cardiac conduction abnormalitiesPrimaquine[3] :

Primaquine 30 mg base/day PO can be used as prophylaxis for short-duration travel to areas with >

90%P vivax Begin 1-2d before travel to malarial areas; discontinue 7d after departure from malarial areas


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Contraindicated in persons with glucose-6-phosphate dehydrogenase (G6PD) deficiency (allpersons who take primaquine should have a documented normal G6PD level before starting)

Also contraindicated during pregnancy and lactation unless the infant being breastfed has adocumented normal G6PD level

Special considerations

To enroll a patient with severe malaria in the artesunate treatment protocol, contact the Centers forDisease Control and Prevention (CDC) Malaria Hotline at 770-488-7788 during business hours (Mon-Fri; 8:00 am to 4:30 pm, Eastern time); after hours, call 770-488-7100 and ask to speak with a CDCMalaria Branch clinician

Quinidine may cause QT prolongation or hypoglycemia; electrocardiography and serum glucosemonitoring are required

Patients prescribed primaquine should be checked for the presence of G6PD deficiency

malaria organism-specific therapy

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