Download Table 1: Criteria for Severe Falciparum Malaria

PEDIATRIC MANAGEMENT GUIDELINES FOR MALARIA TREATMENT
Ammended for publication January 20, 2009 and are located on the local hospital network
Principles of Care in Patients with Malaria
1. This is a medical emergency as death can result rapidly from untreated P. falciparum malaria.
2. All patients with malaria due to P. falciparum must be admitted to hospital or “observation unit”
to ensure tolerance of treatment and to confirm decreasing parasitemia with treatment.
3. If the species is not unequivocally identified, treat as P. falciparum until further identified.
4. Treat all P. falciparum as chloroquine resistant (treatment may only be modified by Infectious
Disease Service).
5. Severe or complicated disease requires management in an intensive care unit setting. (see Table 1)
6. Infectious diseases (ID) consult is required for all positive malaria smears. The Hematology
Laboratory should also notify ID of all positive malaria smears.
Initial Assessment of malaria
Although anyone can have severe or complicated infection with malaria, children, pregnant women and
‘non-immune’ (those individuals who have never had prior infection with malaria) hosts are at greater
risk of complications and/or death. Siblings or family members traveling with the index case of malaria
should also be questioned about fever, headache and malaise since they also are at risk for malaria
acquisition.
Treatment of malaria in a non-immune host is a medical emergency. Patients who have malaria that
is uncomplicated can be admitted and treated with oral medication. However, persons with severe or
complicated malaria or those who cannot tolerate oral medication should be cared for in a monitored unit
and treated with intravenous therapy. Criteria for severe malaria are listed in Table 1.
Malaria parasites may be difficult to find on blood smear and even when identified, determining the
species of plasmodium is often difficult. Furthermore, mixed infections with two types of malaria are
also possible. Since prompt treatment is essential, we have prepared guidelines and admission orders for
disease management in the setting where initial therapy is aimed at Plasmodium falciparum. Initial
therapy should be given in the following clinical settings:
Malaria parasites on blood smear but species not confirmed or P. falciparum confirmed.
OR
If the risk of malaria is high (based on clinical and epidemiologic grounds) and blood smear
results are not immediately available, start empiric therapy as outlined in the Drug Therapy
Section.
Table 1: Criteria for Severe Falciparum Malaria
1. Asexual forms of Plasmodium falciparum on blood smear AND
2. Any one or more of the following clinical or laboratory features:
Clinical:
1. Prostration, impaired consciousness or coma
2. Respiratory distress (acidotic breathing)
3. Pulmonary edema
4. Repeated generalized convulsions
5. Circulatory collapse, shock
6. Spontaneous bleeding/disseminated intravascular coagulation
7. Jaundice
Laboratory
1. Severe normocytic anemia
2. Acidosis
3. Renal failure
4. Hypoglycemia
5. Hemoglobinuria
6. Hyperlactemia
7. Parasitemia of > 5% in non-immune individuals
1. General Admission Orders
Malaria Admission Orders
ADMIT TO:
DIET:
ACTIVITY:
MONITORING:








Ensure Infectious Diseases has been consulted and aware of admission
Temp, HR, RR and BP and neurovitals q4H x 24 hrs, then reassess
Notify physician if Glasgow Coma Scale is less than 14 and do stat blood glucose
O2 saturation q4h x 24 hours, then reassess
Notify physician if O2 saturation is less than 92%
Call physician on call if blood glucose is < 4 mmol/L by finger prick
Strict Intake/output x 24 hrs, then reassess
If intravenous quinine is to be administered to a patient who has taken mefloquine or
halofantrine in the previous 2 weeks, they should be monitored electrocardiographically
(given possible risk of drug-induced cardiac arrhythmia)
INVESTIGATIONS:
STAT (to be done in Emergency department prior to transfer to ward):






Peripheral Blood cultures x 2 sets
CBC diff
glucose
Na, K, Cl, Creat, BUN, ALT, alkaline phosphatase
Urine Analysis (Routine and Microscopy)
Venous or arterial blood gas
Routine



Blood glucose by finger prick q4h x 24 hours
Thick and thin malaria smear q12H x 36 hours, then daily
CBC, glucose, Creat, ALT and AST daily
MEDICATIONS:


IV D5W/0.9% NaCl at _______________mL/hr.
Antimalarial Therapy BEGIN STAT prior to transfer to ward,
_____
Malaria IV Therapy (A)
OR
_____
Malaria Oral Therapy (B)
SEE SEPARATE PRE-PRINTED ORDERS MALARIA DRUG THERAPY
DISCHARGE INSTRUCTIONS:


Please ensure patient has follow-up appointment for 1 week and 4 weeks after discharge with
Infectious Diseases
Please ensure that patient or parent has requisition for blood smears at day #4, #7 and #28
A. Oral Therapy
Oral therapy may be given if patient does not meet the criteria for severe or complicated
malaria (see Table 1) and is able to tolerate oral medication. The following combination
therapies are recommended for the treatment of malaria (suspected to be P falciparum):
1. Atovaquone/ Proguanil (Malarone®)
OR
2. quiNINE capsules or quiniDINE suspension
Plus Doxycycline or clindamycin
MEDICATIONS:
Malarone® (atovaquone 250 mg + proguanil HCl 100 mg) x 3 days
____
< 8 kg: ½ tablet (50 mg proguanil HCl) po once daily x 3 days
____
9 – 10 kg: ¾ tablet (75 mg proguanil HCl) po once daily x 3 days
____
11 – 20 kg: 1 tablet (100 mg proguanil HCl) po once daily x 3 days
____
21 – 30 kg: 2 tablets (200 mg proguanil HCl) po once x 3 days
____
31 – 40 kg: 3 tablets (300 mg proguanil HCl) po once daily x 3 days
____
> 40 kg: 4 tablets (400 mg proguanil HCl) po once daily x 3 days

Give with food or milk

May crush tablets and mix with food or water

May give via NG-tube
 Call physician if oral antimalarial medication is vomited or refused. If vomiting
occurs within 30 minutes of last dose of medication, administer full dose of medication
again. If vomiting occurs between 30 – 60 minutes, repeat half the dose. If vomiting
recurs, call admitting physician to change to parenteral therapy.
OR Alternative Oral Therapy:
QUININE CAPSULES or QUINIDINE SUSPENSION PLUS DOXYCYCLINE or
CLINDAMYCIN
quiNINE CAPSULES or quiniDINE SUSPENSION X 7 days
1. quiNINE oral capsules (patients > 20 kg).
(quiNINE sulfate 200 mg capsule = 166 mg quiNINE base)
 20 – 24 kg: 3 capsules/day = 1 capsule po q8h x 7days
 25 - 29 kg: 4 capsules/day = 1 capsule with breakfast
1 capsule with lunch and
2 capsules with supper po x 7 days
 30 – 34 kg: 5 capsules/day = 1 capsule with breakfast
2 capsules with lunch and
2 capsules with supper po x 7 days
 35 – 44 kg: 6 capsules/day = 2 capsules po q8h x 7days
 45 – 49 kg: 7 capsules/day = 2 capsules with breakfast
2 capsules with lunch and
3 capsules with supper po x 7 days
 50 – 59 kg: 8 capsules/day = 2 capsules with breakfast
3 capsules with lunch and
3 capsules with supper po x 7 days
 >60 kg: 9 capsules/day =
3 capsules po q8h x 7 days
2. quiniDINE oral suspension (patients < 20 kg or unable to swallow capsules).
(CHEO 8.3 mg base/mL)
 ________ mg base po q 8h x 7days (28 mg base/kg/day to a maximum of 1,400 mg
base/day)


Give with food or milk
Contains quiniDINE sulphate
Additional Oral Therapy to be prescribed with quiNINE/quiniDINE:
(Note: quiNINE/quiniDINE therapy requires additional therapy with doxycycline or clindamycin.)
Delay administration to enhance quiNINE/quiniDINE tolerance:
 1 –2 hours
 24 hours
Choose either Doxycycline ( > 8 years old) or Clindamycin (< 8 years old)
 Doxycycline 100 mg capsule
_______ mg po BID x 7 days (4 mg/kg/day)
 Clindamycin 150 mg capsule or 15 mg/mL oral suspension
_______ mg po q 8h x 7 days (20 mg/kg/day)
 Give with food or milk or full glass of water
 May open capsule and sprinkle contents on food
Vomiting after Oral Capsule or Tablet
If vomiting occurs within 30 minutes of the last dose of medication, administer one full
dose of medication again. If the vomiting had occurred between 30 – 60 minutes of the
last dose, repeat one-half of the dose. If vomiting recurs a second time or with a second
dose, the patient’s physician should be contacted as the patient may require intravenous
antimalarial therapy.
Vomiting after Oral Liquid
If vomiting occurs in less than 10 minutes of the last dose of medication, administer one
full dose of medication again. If the vomiting had occurred between 10 – 15 minutes of
the last dose of medication, repeat one-half of the dose. If vomiting recurs a second time
or with a second dose, the patient’s physician should be contacted as the patient may
require intravenous antimalarial therapy.
B. Parenteral Therapy
Parenteral therapy is indicated if:
• the patient meets criteria for severe malaria (See Table 1 )
or
• the patient is unable to tolerate oral drugs (refused or vomiting)
Physician Orders–IV Drug Therapy for patients receiving Intravenous
Therapy
MEDICATIONS:
Day 1, Hour 0:
Loading Dose of IV quiNINE:
_____
Omit loading dose if patient received quiNINE, quiniDINE, or
mefloquine in previous 24 hours
_____
quiNINE base 5.8 mg/kg = __________ mg base

_________ mg base x 1.22 = __________ mg quiNINE
dihydrochloride
(300 mg/mL – supplied as 600 mg/2 mL vial)
(300 mg quiNINE dihydrochloride = 245 mg quiNINE base)

quiNINE dihydrochloride MAX dose = 600 mg
If patient is less than 10 kg, dilute to 5 mg/mL D5W/0.9% NaCl
If patient is greater than or equal to 10 kg, dilute in 50 mL 0.9% NaCl
If patient is greater than or equal to 20 kg, dilute in 100 mL 0.9% NaCl
Give STAT over 30 minutes
Day 1 to 2, Hour 0.5
Maintenance Dose of IV quiNINE:
_____
quiNINE base 8.3 mg/kg/dose = __________ mg base IV q8h

_________ mg base x 1.22 = __________ mg quiNINE
dihydrochloride
(300 mg/mL – supplied as 600 mg/2 mL vial)
(300 mg quiNINE dihydrochloride = 245 mg quiNINE base)

quiNINE dihydrochloride MAX dose = 600 mg
If patient is less than 10 kg, dilute to 2 mg/mL D5W/0.9% NaCl
If patient is greater than or equal to 10 kg, dilute in 250 mL D5W/0.9% NaCl
If patient is greater than or equal to 20 kg, dilute in 500 mL D5W/0.9% NaCl
Start immediately after loading dose and give over 4 hours
Hour 6 :
Day 3:
Clindamycin _______mg IV q6h (25 to 40 mg/kg/day to a maximum of
3,600 mg/day)
Continuation Dose:

Continue Clindamycin IV

Decrease maintenance Dose of IV quiNINE:
_____
quiNINE base 3 mg/kg/dose = __________ mg base IV Q8h

_________ mg base x 1.22 = __________ mg quiNINE
dihydrochloride
(300 mg/mL – supplied as 600 mg/2 mL vial)
(300 mg quiNINE dihydrochloride = 245 mg quiNINE base)

quiNINE dihydrochloride MAX dose = 300 mg
If patient is less than 10 kg, dilute to 2 mg/mL D5W/0.9% NaCl
If patient is greater than or equal to 10 kg, dilute in 250 mL D5W/0.9% NaCl
If patient is greater than or equal to 20 kg, dilute in 500 mL D5W/0.9% NaCl
Give over 4 hours
References
1.
2.
3.
4.
5.
6.
7.
8.
WHO guidelines for the treatment of malaria, 2006 [webpage];
http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf.
Severe and complicated malaria. 2nd ed. Trans Roy Soc Trop Med Hyg 1990; 84 (Suppl). Adapted in:
Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers.
CATMAT 2004-06-28.
Gilbert DN. The Sanford Guide to Antimicrobial Therapy 2006, 36th edition. Sperryville, VA, USA:
Antimicrobial Therapy, Inc.
Lau E, editor. 2007-2008 Formulary. The Hospital for Sick Children. Toronto, Ontario, Canada
Taketomo C et al. Pediatric Dosing Handbook . 14 th edition. Hudson, Ohio: Lexi-Comp; 2007.
Medical Access to quiNINE for Malaria Treatment Streamlined in Canada through the Canadian Malaria
Network. CCDR 2004-02-02.
Bradly JS, Nelson JD. 2006-2007 Nelson’s Pocket Book of Pediatric Antimicrobial Therapy. 16 th edition.
Buenos Aires, Argentina: AWWE; 2006.
Pickering LK, Baker CJ, Long SS, McMillan JA, editors. Red Book: 2006 Report of the Committee on
Infectious Diseases. 27th edition. Elk Grove Village, IL: Academy of Pediatrics; 2006.
18 February 2009