Management of malaria with special reference to drug resistance.

Abstract

The management of acute malaria consists of chemotherapy to destroy asexual forms of malaria parasites, and amelioration of the pathophysiologic changes to restore the normal function of all organs. In choosing appropriate drug for the treatment of malaria, the sensitivity of the parasites to the drug must be considered. The regimen recommended are as follows : 1) in areas where P. falciparum is sensitive to 4-aminoquinolines, for the non-immunes without complications, chloroquine or amodiaquine 300 mg base t.i.d. on the first day then once daily for 2-4 days; for semi-immunes, chloroquine or amodiaquine 600mg base single dose. 2) in 4-aminoquinoline resistant areas but sensitive to antifol/sulfa combinations, sulfadoxine or sulfalene 1, 500mg plus pyrimeth-amine 75mg single dose (Fansidar or Metakelfin 3 tab.); for non-immunes without complications, quinine or quinidine 600mg every 8 hr for 2-3 days will accelerate the clearance of fever and parasitaemia. 3) in areas with resistance to both 4-aminoquinolines and antifol/sulfa combinations, quinine or quinidine 600mg every 8 hr for 7 days. 4) in areas with resistance to 4-aminoquinolines, antifol/sulfa combinations and quinine4.1 quinine 600mg every 8 hr plus tetracycline 250mg b. i. d. for 500mg b. i. d. for 7 days. 4.2 mefloquine 750-1, 000mg single dose.4.3 MSP (mefloquine 250mg, sulfadoxine 500mg + pyrimethamine 25mg) 3 tablets single dose;in areas with natural transmission of malaria, primaquine 30-45mg single dose to eradicate gametocytes and interrupt transmission.Severe malariaIf the patients is seriously ill or has over 5% parasitaemia chloroquine or quinine should be given paresterally as follows : -chloroquine 2.5mg/kg subcutaneously or intramuscularly every 4 hr or 3.5mg/kg every 6 hr or continuous intravenous of 10mg/kg in 8 hr followed by 5mg/kg in 8 hr then 2 doses of 5mg/kg every 12 hr to a total dose of 25mg/kg.quinine hydrochloride 20mg/kg in 500 ml/ of 5% dextrose or normal saline solution intraveneous drip in 4 hr followed by 10mg/kg every 8 hr until oral therapy can be administered. A total dose for an adult weighing 60 kg is 13, 000mg in 7 days.Complications or pathophysiologic changes e. g. coma, convulsions, hypoglycaemia, hyperpyrexia, anaemia, dehydration, renal failure, pulmonary oedema, jaundice, electrolytes and acid-base disturbances etc. must be corrected by effective measures.Steroids, mannitol, dextran, heparin and adrenaline are not recommended as they seem to do more harm than good.Vivax malariaChloroquine 600 mg single dose or 300 mg twice 6 hr apart followed by primaquine 15 mg daily for 14 days.Ovale malariaChloroquine 600 mg, followed by 300 mg after 6 hr then 300 mg daily for 2 days and primaquine as in vivax malaria.Malariae malariaChloroquine as in ovale malaria.