<b>Uncomplicated Malaria</b><br><b>All patients: including children <4 months of age and pregnant women in 2nd and 3rd trimesters</b>:<br>First line medicine ffArtemether/Lumefantrine<br>First line alternative ffArtesunate/Amodiaquine<br>Second line medicine ffDihydroartemisin/ Piperaquine ffIf not available: quinine tablets }<b>Pregnant women 1st trimester</b><br>ffQuinine tablets ffACT may be used if quinine not available<br><b>All age groups or patient categories</b><br>First line ffIV Artesunate<br>First line alternative ffIV Quinine ffOr Artemether injection<br>Pre-referral treatment ffRectal artesunate}<b>Intermittent preventive treatment in pregnancy</b><br>ffSulfadoxine/Pyrimethamine (SP) for IPT. Start at 13 weeks and give monthly till delivery}<b>Management of severe malaria</b><br><b>General principles</b>ffManage complications as recommended in the section below ffManage fluids very carefully. Adults with severe malaria are very vunerable to fluid overload, while children are more likely to be dehydrated ffMonitor vitals signs carefully including urine output ffIntravenous artesunate is the medicine of choice –– At a health unit without admission and IV drug administration facilities, give a pre-referral dose of rectal artesunate ( see dosing tables below) as soon as possible and refer for further management –– At a health unit with admission and IV drug administration facilities, treat with IV artesunate as in the table below –– If IV route is not possible, use IM route --ffIf artesunate not available, use IM artemether (into the thigh, never in the buttock) or IV quinine}<b>Management of Complications of Severe Malaria</b><br><b>Hyperpyrexia</b>ffGive paracetamol 1 g every 6 hours Child: 10 mg/kg + tepid sponging + fanning}<b>Convulsions</b>ffGive diazepam 0.2 mg/kg (max 10 mg) slow IV or (in adults) IM or 0.5 mg/kg rectally If convulsions still persist: ffGive phenobarbital 200 mg IM/IV Child: 10-15 mg/kg loading dose then 2.5 mg/kg once or twice daily if still necessary or ffOr phenytoin 15 mg/kg loading dose}<b>Hypoglycaemia</b>ffAdult: dextrose 25% 2 ml/kg by slow IV bolus over 3-5 min (to prepare, take dextrose 50% 1 ml/kg and dilute with an equal volume of water for injections) ffChild: dextrose 10% 5 ml/kg by slow IV bolus over 5-7 min (to prepare, take 1 ml/kg of dextrose 50% and dilute with 4 ml/kg water for injection) ffDO NOT GIVE UNDILUTED 50% dextrose ffMonitor blood glucose frequently ffEnsure patient is feeding}<b>Acidosis</b> ffCorrect fluid & electrolyte balance ffIf there is severe acidosis without sodium depletion: –– Give sodium bicarbonate 8.4% infusion 50 ml IV –– Monitor plasma pH}<b>Severe anaemia</b>ffDo blood grouping and crossmatching ffTransfuse patient with packed cells 10-15 ml/kg or whole blood 20 ml/ kg especially if the anaemia is also causing heart failure ffRepeat Hb before discharge and preferably 28 days after discharge}<b>Pulmonary Oedema</b>ffRegulate the IV infusion (do not overload with IV fluids) ffProp up the patient ffGive oxygen ffGive furosemide 1-2 mg/kg}<b>Acute Renal Failure</b>ffUrine output: <17 ml/hour for adult or <0.3 ml/kg/hour for a child ffCheck to ensure that the cause of oliguria is not dehydration or shock ffIf due to acute renal failure: Give a challenge dose of furosemide 40 mg IM or slow IV (child: 1 mg/kg) If this fails: ffRefer for peritoneal dialysis or haemodialysis}<b>Shock</b>ffIf systolic BP <80 mmHg (adult) or <50 mmHg (child) or if peripheral pulse absent and capillary refill is slow (>2 seconds) –– Raise the foot of the bed –– Give sodium chloride 0.9% by fast IV infusion bolus 20 ml/kg in 15 min –– Review fluid balance and urinary outputs –– Look for evidence of haemorrhage or septicaemia and treat accordingly}<b>Haemoglobinuria (intravascular haemolysis)</b>ffRehydrate the patient ffAssess for anaemia and transfuse if necessary}<b>Dehydration</b> ffRehydrate using ORS or IV RL or NS (see rehydration, section 1.1.3) ffOver-enthusiasitc IV infusion may harm the patient and lead to fluid overlaod and pulmonary oedema}<b>Bleeding</b> ffTransfuse patient with whole fresh blood to provide lacking clotting factors}<b>Coma</b>ffCheck and treat for hypoglycaemia: if not responding within 20 min, consider another cause ffProvide intensive nursing care with: –– IV drip (for rehydration and IV medication) –– NGT (for feeding and oral medication) –– Urethral catheter (to monitor urine output) –– Turning of patient frequently to avoid bed sores}<b>Criteria for referral to regional/tertiary hospital</b> yy Persistent renal failure needing dialysis yy Any complication that cannot be managed locally}<b>Management of RDT/Blood Smear Negative Patients</b><br>Patients who have a negative malaria test (most likely, if RDT is used) do not have malaria so other causes of fever have to be investigated for appropriate treatment. yy Re-assess patient history, clinical signs and laboratory results. Consider other frequent causes of fever such as: –– If running nose, sore throat and cough: viral upper respiratory infection –– If swollen tonsils with exudate on it: tonsilitis –– If ear pain and discharge: otitis –– If cough, rapid breathing and difficulty in breathing: pneumonia –– If urinary symptoms: urinary tract infection –– If vomiting, diarrhoea and abdominal pain: gastroenteritis –– If skin rash: measles or other viral rash yy If malaria is still suspected, investigate according to the flowchart below –– If signs/symptoms of severe malaria, RDT and blood slide negative but no other diagnosis is found, consider treating for malaria anyway but repeat RDTs after 24 hours to confirm –– If RDT and blood slide negative, no signs of other illness and no signs of severe sickness (patient has no danger signs) treat symptomatically with antipyretics, advise patient to return immediately if condition worsens or in 2 days if fever persists.}<b>Possible reasons for false negative tests (test is negative but patient has malaria):</b><br>yy Low peripheral parasitaemia yy Technical error in performing the test or test reagents that are out of date yy Sequestration of parasites in the internal organs yy Having already taken antimalarial drugs, inadequate or incomplete dose: this affects only microscopy, while RDT remains positive even if the patient has already taken an antimalarial yy Using prophylactic treatment for malaria}<b>Malaria Prophylaxis</b><br> Not recommended for all those living in a highly endemic area like Uganda. However, it is recommended for certain high-risk groups but is not 100% effective.<br><b>Pregnancy In endemic areas, pregnant women carry malaria parasites in their blood or placenta, which is harmful to the health of both mother and foetus</b>ffGive intermittent preventive treatment (IPT) to ensure the well-being of mother and foetus ffSP single dose (3 tabs) given at 13 weeks and continued monthly until delivery ffEnsure doses are taken under supervision by the health provider as directly observed therapy (DOT) ffRecord doses on the patient’s card and treatment register and summarise further in the delivery book and monthly returns ffDo not give SP in HIV patients on cotrimoxazole<br><b>Sicke cell disease</b>ffChloroquine Adult: 300 mg base weekly Child: 5 mg (base)/kg weekly ffor Sulphadoxinepyrimethamine (SP)<br><b>People living with HIV</b>ffCotrimoxazole daily as per national guidelines<br><b>Non-immune visitors/tourists</b>ffMefloquine Adult: 250 mg once weekly Child: 5 mg/kg once weekly