What is the detailed medical treatment for malaria?

Detailed Medical Treatment of Malaria

Artemisinin-based combination therapy (ACT) is the first-line treatment for uncomplicated Plasmodium falciparum malaria, with artemether-lumefantrine being highly effective with cure rates exceeding 95%, while intravenous artesunate is the treatment of choice for severe malaria. 1

Diagnosis

• Microscopy: Gold standard for malaria diagnosis, allows calculation of parasitemia percentage and monitoring treatment response
• Rapid Diagnostic Tests (RDTs): Use when qualified microscopists are unavailable
• Nucleic Acid Amplification Tests (NAATs): 10-100 times more sensitive than microscopy or RDTs

Treatment of Uncomplicated Malaria

P. falciparum and P. knowlesi

1. First-line treatment: Artemisinin-based Combination Therapy (ACT)

   • Artemether-lumefantrine: Total of 24 tablets for adults >35kg, taken with food
     • Dosing: Four tablets as a single daily dose for 3 consecutive days 1, 2
     • Must be taken with fatty meal to enhance absorption 1
   • Atovaquone-proguanil: Alternative for patients with QT prolongation risk or from Southeast Asia with high ACT resistance
     • Dosing: 4 tablets daily for 3 days for adults >40kg 1, 2
     • Clinical trials show 100% efficacy in evaluable patients 2

2. Alternative regimens (when ACTs unavailable or contraindicated):

   • Quinine sulfate plus doxycycline or clindamycin 1
   • Mefloquine 1

P. vivax, P. ovale, P. malariae

1. Blood stage treatment:

   • Chloroquine: Drug of choice for chloroquine-sensitive infections 1, 3
     • Total dose: 25 mg base/kg over 3 days
     • Adults: 600 mg (base) initially, then 300 mg at 6,24, and 48 hours 3
     • Children: 10 mg base/kg followed by 5 mg base/kg at 6,24, and 36 hours (total 25 mg base/kg) 3

2. Radical cure (for P. vivax and P. ovale to eliminate liver hypnozoites):

   • G6PD testing required before administration
   • Primaquine: 15 mg (base) daily for 14 days 1
   • Tafenoquine: Single 300 mg dose 1

Treatment of Severe Malaria

• First-line treatment: Intravenous artesunate 1, 4
• Monitor parasitemia every 12 hours until <1%, then every 24 hours until negative 1
• Monitor for post-artesunate delayed hemolysis (PADH) at days 7,14,21, and 28 1

Special Populations

Pregnant Women

• Artemether-lumefantrine is endorsed for use in all trimesters of pregnancy 1
• Primaquine and tafenoquine are contraindicated during pregnancy 1
• Defer anti-relapse therapy until after pregnancy 1
• Chloroquine is safe during pregnancy for blood-stage treatment 1, 3

Renal Impairment

• For quinine: Loading dose of 648 mg followed 12 hours later by maintenance doses of 324 mg every 12 hours 1
• Atovaquone-proguanil should not be used for malaria prophylaxis in severe renal impairment (creatinine clearance <30 mL/min) 2
• Atovaquone-proguanil may be used with caution for treatment in severe renal impairment if benefits outweigh risks 2

Hepatic Impairment

• Avoid quinine in severe hepatic impairment 1
• Monitor closely if mild to moderate hepatic impairment 1
• No dosage adjustments needed for atovaquone-proguanil in mild to moderate hepatic impairment 2

Monitoring Treatment Response

• For uncomplicated malaria: Monitor parasitemia every 24 hours until negative 1
• For severe malaria: Monitor parasitemia every 12 hours until <1%, then every 24 hours until negative 1
• Check hemoglobin, haptoglobin, and lactate dehydrogenase levels to monitor for hemolysis 1

Resistance Considerations

• P. falciparum has developed resistance to chloroquine in most regions worldwide 1
• Increasing artemisinin resistance in Greater Mekong sub-region and parts of Africa requires vigilant monitoring 1
• In areas with known resistance, use alternative regimens based on local resistance patterns 1

Pediatric Considerations

• ACT regimens are effective in children, with dosing based on weight 1, 5
• The six-dose regimen of artemether-lumefantrine has shown high efficacy (>93% when PCR-corrected) in African children 5
• Children are at higher risk for severe malaria and require prompt treatment 4

Prevention

• Travelers to endemic areas should take preventive measures:
  • Insecticide-treated bed nets
  • Protective clothing
  • Insect repellents
  • Appropriate chemoprophylaxis 1

The treatment of malaria requires prompt diagnosis and species-specific therapy to ensure optimal outcomes. ACTs remain the cornerstone of treatment for uncomplicated P. falciparum malaria, while chloroquine plus primaquine/tafenoquine is essential for P. vivax and P. ovale infections to prevent relapse. Severe malaria requires immediate intravenous artesunate and intensive monitoring.