What is the recommended evaluation and treatment for malaria?

Malaria Evaluation and Treatment Guidelines

The recommended evaluation for malaria includes thick and thin blood smears with Giemsa stain for diagnosis, followed by treatment with artemisinin-based combination therapy (ACT) for uncomplicated P. falciparum malaria or chloroquine for sensitive strains, while severe malaria requires immediate intravenous artesunate. 1

Diagnostic Approach

• Thick and thin blood smears with Giemsa stain should be the basis for diagnosis of malaria, allowing for species identification and quantification of parasitemia 1
• Any febrile traveler returning from an endemic area should undergo laboratory testing for malaria, as delayed diagnosis increases mortality 1
• Rapid antigen detection tests (RDTs) should be used as an initial screening test but should not replace microscopy techniques 2
• If an expert microscopist is not available, use a sensitive RDT to rule out P. falciparum infection immediately while preparing slides for later expert review 2
• If the first microscopic examination and RDT are negative but clinical suspicion remains high, tests should be repeated daily 2

Treatment of Uncomplicated Malaria

P. falciparum Malaria

• Oral artemisinin-based combination therapy (ACT) is the first-line treatment for uncomplicated P. falciparum malaria 1, 3
• In areas without chloroquine resistance, chloroquine can be used at a total dose of 1,500 mg (approximately 25 mg/kg body weight) given over a 3-day period 1, 4
• For adults: 1000 mg initially, followed by 500 mg at 6,24, and 48 hours 5
• For children: 10 mg/kg, 10 mg/kg, and 5 mg/kg body weight at 0,24, and 48 hours, respectively 4
• When artemisinin-based combinations are unavailable, alternatives include atovaquone-proguanil or quinine plus clindamycin 3

P. vivax, P. ovale, P. malariae, and P. knowlesi Malaria

• Either chloroquine or oral ACT can be used for treatment of uncomplicated non-falciparum malaria 1
• For P. vivax or P. ovale infections, add primaquine (15 mg daily for 14 days in adults; 0.3 mg/kg/day in children) to eliminate liver hypnozoites and prevent relapse 4, 1
• Before administering primaquine, patients must be tested for glucose-6-phosphate dehydrogenase (G-6-PD) deficiency to avoid potentially life-threatening hemolysis 4, 1
• In populations with severe G-6-PD deficiency (notably among Asians), primaquine should not be administered for more than 5 days 4

Treatment of Severe Malaria

• Severe malaria is a medical emergency requiring prompt and specific treatment 4, 6
• Intravenous artesunate is the first-line treatment for severe malaria 6, 3, 7
• Dosing regimen: 2.4 mg/kg IV at 0,12, and 24 hours, then daily until oral therapy can be started 6
• If intravenous artesunate is unavailable, intravenous quinine dihydrochloride can be used as a second-line option 6
• Quinine dosing: 20 mg/kg loading dose over 4 hours, followed by 10 mg/kg every 8 hours 6
• After three doses of IV artesunate and when parasite levels are <1%, patients can be switched to oral ACT therapy 1, 6
• Monitor parasitemia every 12 hours until it declines to <1%, then every 24 hours until negative 6

Special Considerations

Pregnant Women

• Pregnant women with malaria should be treated aggressively using adult regimens 4
• Chloroquine is safe during pregnancy 4
• Quinine is also safe during pregnancy, though pregnant women receiving IV quinine should be monitored carefully for hypoglycemia 4

Monitoring During Treatment

• When laboratory analysis is performed, the first dose of antimalarial medication should be administered when the blood smear is taken 4
• Patients who remain symptomatic longer than 3 days into therapy should have a repeat thick smear examination 4
• For severe malaria, monitor full blood count, hepatic, kidney, and metabolic parameters daily 1
• After artesunate therapy, monitor for delayed hemolysis on days 7,14,21, and 28 1, 6

Fever Control

• Antipyretics (acetaminophen, paracetamol) and anticonvulsives are often necessary for malaria patients 4
• Children with high fevers should be frequently sponged with tepid water 4
• Patients should increase fluid intake as febrile illness is often accompanied by mild dehydration 4
• Patients with signs of moderate dehydration should be given oral rehydration solution (ORS) 4

Chemoprophylaxis

• Travelers to malaria-endemic regions should receive appropriate chemoprophylaxis 4, 7
• In areas without chloroquine resistance, weekly chloroquine (300 mg base) is recommended 4
• In areas with chloroquine resistance, mefloquine (250 mg weekly) is recommended 4
• Chemoprophylaxis should begin 1-2 weeks before travel (except for doxycycline, which can begin 1-2 days before) and continue during travel and for 4 weeks after leaving malarious areas 4
• Personal protection measures should also be used, including remaining in well-screened areas, using mosquito nets, wearing protective clothing, and applying insect repellents containing DEET 4