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![1.EXO-ERYTHROCYTIC SCHIZOGONY
STAGE
• During a blood meal, a malaria-infected female
anopheles mosquito inoculates sporozoites into the
human host
• Sporozoites infect liver cells (2) and mature into
schizonts , which rupture (3) and release
merozoites (4).
• NOTE: in P. vivax and P. ovale a dormant stage
[hypnozoites] can persist in the liver (if untreated)
and cause relapses by invading the bloodstream
weeks, or even years late](https://image.slidesharecdn.com/malariapreejay-250217152436-2a905cdf/75/Malariapreejay-pptx-educating-and-keepin-6-2048.jpg)
Malariapreejay.pptx educating and keepin
- 1. THE UNIVERSITY TEACHINGHOSPITALS MALARIA Presented by:Elijah Chimbini. Intern Pharm Supervisor:Pharmacist Nalili Department:Obs/Gyn
- 2. Content • introduction • LifeCycle • Clinical presentations of Malaria • Malaria Diagnostic tests • Prophylaxis for Malaria • Goals of therapy • Treatment of Malaria in different populations • Reconstitution and Administration of Artesunate and Quinine • Prevention and Control of Malaria
- 3. Introduction • Parasitic infectioncaused by plasmodium spp and transmitted by female anopheles’ mosquito. • There are five types of plasmodium spp namely; • 1.P. knowlesi, • 2.P. ovale, • 3.P. vivax, • 4.P Falciparum and • 5.P. malariae. • • It can be classified into uncomplicated and Complicated
- 4. MALARIA CYCLE • Themalaria parasite cycle involves two hosts; (1) humans and (2) female mosquitos. • The cycle is divided into 3 stages; 1. exo-erythrocytic schizogony, 2. Erythrocytic Schizogony stage and 3. Sporogenic stage. • The first two stages take place in humans and are referred to as Asexual replication stage. • Sporogenic stage/cycle is a Sexual replication Stage and occur in female mosquitos
- 6. 1.EXO-ERYTHROCYTIC SCHIZOGONY STAGE • Duringa blood meal, a malaria-infected female anopheles mosquito inoculates sporozoites into the human host • Sporozoites infect liver cells (2) and mature into schizonts , which rupture (3) and release merozoites (4). • NOTE: in P. vivax and P. ovale a dormant stage [hypnozoites] can persist in the liver (if untreated) and cause relapses by invading the bloodstream weeks, or even years late
- 7. 2.ERYTHROCYTIC SCHIZOGONY STAGE •After the liver stage, the parasites undergo asexual multiplication in the erythrocytes (erythrocytic schizogony). Merozoites infect red blood cells (5). • The ring stage trophozoites mature into schizonts, which rupture releasing merozoites (6). Some parasites differentiate into sexual erythrocytic stages (gametocytes) (7). • NOTE: Blood-stage parasites are responsible for the clinical manifestations of the disease.
- 8. 3.SPOROGONIC STAGE • Inthe mosquitos' stomach, microgametes penetrate the macrogametes generating zygotes (9) • The zygotes matures into ookinetes (10) which invade the midgut wall of the mosquito where they develop into oocysts (11). • The oocysts grow, rupture, and release sporozoites (12), which make their way to the mosquito’s salivary glands. • Inoculation of the sporozoites (1) into a new human host perpetuates the malaria life cycle
- 9. DIAGNOSIS OF MALARIA •The features of malaria are non-specific and can mimic other diseases like viral infections, bacterial infections (e.g.,enteric fever) among others. • Therefore, all clinically suspected malaria cases should be promptly confirmed either by microscopy or malaria RDT.
- 10. CLINICAL PRESENTATIONS Complicated Malaria •Hypoglycemia, • unconscious, • severe anaemia, • Acidosis • Jundiced • Shock(Algid Bp 90/60mmhg)/Excessive vomiting • Cerebral malaria Uncomplicated Malaria • Fever • Chills • Rigors • Nausea and vomiting • Headache • Anorexia • Myalgia
- 11. DIAGNOSTIC TESTS a. MalariaRapid Diagnostic Tests (mRDTs) • All suspected uncomplicated malaria cases at all levels of the health care delivery system should be tested using an mRDT prior to initiating treatment. • Advantages of mRDTs: 1.They provide a quick result; 2.They are less expensive than microscopy; 3.Their use is readily taught.
- 12. Cont... • Disadvantages ofmRDTs: 1.They continue to be positive in patients who have recently (within two weeks) been treated with effective anti-malarial medicines; 2.They cannot indicate parasite density
- 13. Cont... b. Microscopy • Microscopyof thick and thin blood smears remains the gold standard for confirmation of diagnosis of malaria. • Thick films are recommended for parasite detection and quantification and can be used to monitor response to treatment. • Thin films are recommended for species identification.
- 14. Cont... • The advantagesof microscopy are: 1.High specificity when used by a competent microscopist. 2.Ability to quantify the parasite load. 3.Ability to identify malaria parasite species and their different stages. 4.Ability to detect other blood parasites and conditions. 5.It helps in monitoring the response to treatment.
- 15. MALARIA PROPHYLAXIS • ChloroquineResistant Areas • Artovaquone plus praguanil 250mg OD a 1-2 days before departure continue during visit then take for 7 days after coming back. • Mefloquine 250mg po od a week before travelling, continue during the visit, discontinue 4 weeks after the visit. Not recommended in depression, schizophrenia, psychosis, anxiety disorder etc. • Primaquine given once weekly at dose of 15-30mg starting a day before travelling, continue during visit then discontinue after a week after the visit. • Doxycycline 100mg once daily, same as Artovaquone
- 16. Cont.. • Chloroquine SensitiveArea • Chloroquine 300-400mg weekly • Hydrochlororquine 400-800mg given a week before departure, continue after departure until 4 weeks after coming back.
- 17. TREATMENT- GOALS OFTHERAPY Prompt diagnosis and complete treatment of malaria aims to: 1.Cure 2.Prevent the progression of uncomplicated malaria to severe disease 3.Prevent deaths 4.Minimize risk of emergence of drug resistant parasites
- 18. UNCOMPLICATED MALARIA First-line Treatment •In Adults and Children weighing 5kg and above; Artemether (20mg)-Lumefantrine (120mg) • Given based on Body weight; a. 5-14.9kg = 1 tablet b. 15-24.9kg = 2 tablets c. 25-34.9kg = 3 tablets d. 35kg & above = 4 tablets • Give at 0, 8, and then 12 hourly for 3 days, taken with a highly fatty meal
- 19. Cont... Alternative to 1stLine treatment • Dihydroartemisin-piperaquine (DHA-PQ) OD for 3/7 • Single Strength: DHA-PQ (20/160)mg • Double Strength: DHA-PQ (40/320)mg • Children < 25kg treated with DHA-PQ should receive a minimum of 2.5 mg/kg body weight (bw) per day of dihydroartemisinin and 20 mg/kg bw per day of piperaquine daily for 3 days. • Artovaquone /praguanil (250/100mg); given as 4 tablets once daily.
- 20. Note: • It isrecommended that each dose of AL should be taken with food to optimize absorption. • Milk has been shown to improve the absorption of the lumefantrine component of the combination. • The dose should be repeated if the medicine is vomited within 30 minutes of ingestion.
- 21. CHILDREN WEIGHING BELOW5KG • 1st line:Pyrimethamine 25mg-sulfadoxin 500mg(Fansidar) is the drug of choice. • 2nd line: Oral Quinine (10 mg/kg body weight) every 8 hrs for 7 days plus Clindamycin (20 mg/kg body weight) every 8 hrs for 7 days
- 22. Age (in Years)No. Of tablets Dosage Strength Less than 1 yrs 1/4 tab 300mg 1-3 yrs 1/2 tab 300mg 4-6 yrs 3/4 tab 300mg 7-11 yrs 1 tab 300mg 12-15 yrs 3/2 tabs 300mg Above 15 yrs 2 tabs 300mg Second-line treatment • Oral Quinine is drug of choice in failure to 1st line • Dose: (10mg/kg)TDS for 7 days
- 23. COMPLICATED MALARIA ADULTS &CHILDREN • 1st Line Drug: Artesunate (IV or IM) • Dose: 2.4mg/kg adults and 3.0mg/kg children at time 0,12,24 then once daily. • Treats multi-drug resistant parasites and clears parasites rapidly. • Alternative to 1st line: Parenteral Quinine (IV or IM) • LD: QUININE I.V 20mg/kg in 10ml/kg 5 or 10% dextrose over 4hours, then; • MD: QUININE I.V 10mg/kg in 10mls/kg of dextrose over 4 hours repeated every 8 hours. • Change to oral quinine or AL when patient is able to take orally.
- 24. Cont.. • For adults,if the patient can be weighed, intravenous quinine is administered in the same manner as for children. If the patient cannot be weighed, IV quinine should be given as follows: 1. First dose 900 mg in one litre of 5% dextrose given over 4 hrs 2. Subsequent doses 600 mg in one litre 5% dextrose every 12 hours given over 4 hours 3. Continue the same IV fluids or Ringer’s lactate (10 ml/kg given over 4 hours) between doses of quinine (Give a maximum of about 3 litres per 24 hours to avoid fluid overload)
- 25. TREATMENT OF MALARIAIN PREGNANCY Uncomplicated Malaria 1.First trimester of pregnancy • Quinine 600mg tds P.O plus Clindamycin 300mg tds P.O for 7 days Note: If there is a confirmed treatment failure for pregnant women in the 1st trimester, give AL. 2.Second and third trimester of pregnancy • Use AL or DHA-PQ in the second and third trimesters of pregnancy, in the usual adult dose.
- 26. Intermittent Preventive Treatment •Sulfadoxine-pyrimethamine (500/25mg) started between 13-16 weeks of gestation, given every after 4 weeks(3tabs) up to 6 doses MAY be given.
- 27. Complicated Malaria inPregnancy 1.First trimester of pregnancy • Parenteral Quinine (IM or IV) • LD: 20 mg/kg body weight • MD: 10 mg/kg 12-hourly • When the patient is able to take oral medication and at least 24 hours of parenteral therapy has been administered. Switch to Oral Quinine 600mgs TDS to complete the 7 days course
- 28. Second and Thirdtrimesters First-Line; Parenteral Artesunate (IM or IV) • Give artesunate 2.4 mg/kg body weight IV bolus or IM on admission (at 0 hour), repeat at 12 hours and at 24 hours, then once daily, for no more than 6 days. • However, once patient can take oral treatment and at least 24 hours of parenteral therapy, commence a full course of AL. • Alternative to 1st line: Parenteral Quinine IV or IM
- 29. ARTESUNATE OF RECONSTITUTION ArtesunateFor IV bolus injection, 1. Each vial of injectable Artesunate 60mg must be reconstituted with 1 ml of sodium bicarbonate, then shake for 2 to 3 minutes until the solution is clear. 2. Dilute with 5mls of normal saline or 5% dextrose to make up a total Volume = 6 ml) 3. Dose = 2.4 mg/kg body weight ÷ 10 mg/ml, or 0.24 ml/kg body weight (round up to nearest ml). 4. Withdraw appropriate volume in a syringe and inject IV bolus over 5 minutes.
- 30. Number of Vialsrequired for IV administration • To prepare IV Artesunate, weigh the patient and determine the number of vials needed for treatment, according to the table below:
- 31. ARTESUNATE RECONSTITUTION Intramuscular (IM)Artesunate injection 1. Each vial of injectable Artesunate 60mg must be reconstituted with 1 ml of sodium bicarbonate. Shake for 2 to 3 minutes until the solution is clear. 2. Dilute with 2 ml of 5% dextrose solution or normal saline (0.9% sodium chloride) to produce a 20 mg/ml solution. (Total volume= 2ml) 3. Dose = 2.4 mg/kg body weight ÷ 20 mg/ml, or 0.24 ml/kg body weight (round up to nearest ml). 4.Withdraw into syringe and inject slowly
- 32. Cont.. • Give onadmission (time = 0), then at 12 h and 24 h, then once a day. • Should be injected into the upper, outer quarter of the anterior of the thigh. • Caution: Do not inject Artesunate into the buttocks! • The solution should be prepared freshly for each administration.
- 33. Cont.. • After initialparenteral treatment for a minimum of 24 hrs (thus 3 doses), discontinue parenteral therapy once the patient regains consciousness and can take medications orally, and commence full course of Artemether-lumefantrine (Coaterm). • There should be an interval of at least 8 hrs between the last dose of Artesunate and the first dose of Coartem.
- 34. QUNINE ADMININSTRATION Quinine I.VInjection • In Adults and Children: • Loading Dose: of 20 mg/kg body weight (max 1200 mg) diluted in 10 ml/kg of 5% or 10% dextrose (or isotonic fluid if hypoglycaemia is excluded) per kg body weight by IV infusion over 4 hrs. • After 8 hrs, give a maintenance dose of 10 mg/kg body weight over 4 hrs, repeated every 8 hrs until patient can swallow, • Then oral quinine 10 mg/kg body weight every 8 hrs to complete a 7-day course of treatment.
- 35. QUNINE ADMININSTRATION Intramuscular (IM)injection • In Adults and Children • Dose: l0 mg/kg body weight (maximum 1200 mg) diluted in Normal saline or water for injection (to a concentration of 60–100 mg salt/ml), repeated after 4 hrs then every 8 hrs. This should be given preferably on the anterior thigh. • A maximum of 3 ml should be injected into one site. If the amount to be injected exceeds 3 ml, use multiple sites. • A loading dose is not recommended for IM quinine.
- 36. COMPLICATIONS OF MALARIA •Shock • Altered consciousness and/or Seizures • Severe anaemia • Metabolic acidosis • Severe hypoglycaemia • Spontaneous bleeding or coagulopathy • Acute pulmonary oedema • Acute kidney injury in adults • Sepsis
- 37. MONITORING PATIENTS • Fullblood count (FBC) • Blood glucose level • Liver function tests (LFTs) • Urea and electrolytes (U/Es) • In ill patients, arterial blood gases, blood culture, lactate and clotting studies • (prothrombin time) should also be performed. • Lumbar puncture to exclude meningitis should be considered in febrile • patients with impaired consciousness or repeated seizures. • Urine dipstick and culture, stool culture and chest X-ray may be appropriate.
- 38. PREVENTION & CONTROLOF MALARIA 1. Sleeping under a treated mosquito net. 2. Repellants contact rub-on, mosquito coils 3. Cutting long grasses 4. Spraying and burying stagnant waters 5. Taking prophylaxis medication.
- 39. Pharmaceutical care plan PatientDetails • Name: BS • Gender:Female • Age:15 yrs • occupation : Mtendere • Date of addimision:01/02/24 • Ward: Bo3 • The patient was additted at the university teaching hospital as a clinical referral from chilenge first level one hospital for further management of preterm labour and malaria. • Vital on admission • Temp: 36.7C • Bp :64/38 mmHg • PR: 108b/min • RR:20b/min • Pg:32/40 weeks • Weight:47.1kg
- 40. Patient presenting complaint: •Headache • Backache,lower abdominal pain,leg pain for 1/52 • Fever • Chills • Weakness • Passing dark urine for 4/7 • Perceiving fetal movement Past medical history: • no noted post admission • No noted surgical history • Rvd negative • No pallor, no jaundice, no cyanosis, no epilepsy Family History • No Diebetes,no epilepsy, no asthma, no tuberculosis, no hypertension Drug history • folic acid • Ferrous sulphate OBSTETRIC HISTORY • gravida 1 para 1 at 32+4/40 weeks.
- 41. Social history: • Married,thepatient was immediately off when the parents discovered that she was pregnant • Currently living at the boyfriend's parents house,the boyboyfriend Is 22 years • the patient currently living at farm area in kafue • Went up to grade 7 • Sleep under the mosquito net • Does not take alcohol • Does not smoke On examination: • febrile to touch • Chest was clear • S1S2 regular • Bp 81/49mmhg • Dark coloured urine • No para, no jaundice, no cynosis • P/A soft
- 42. Urinalysis: • Parasitemia:3+ • Leukocytes:1+ •Ph 6.0 • Bililubin:trace Plan • FBC • LFT • Iv fluids • X match 20 • Start Artesunate 2.4mg/kg iv at 0,12,24hrs • Coartem 4 tabs po bd 3/7 after Artesunate • RBS profile • Obs scan • To start tocolytics with nifedipine 20mg start then 10mg tds • Continue haematinics
- 43. INVESTIGATIONS DONE • Obstetricsscan at 02/02/25 at 32 weeks • - Fragile intra uterine • -SPH = 36cm cephalic • - GA = 32 + 4 • - Adequate amniotic fluid • - Number of Feti: 01 • - Presentation: Transverse right • - Liqour volume: Adequate • - Placenta location: Anterior • - Fetal anatomy: Normal • - Fetal movement: Seen • - Fetal heart rate: 129bpm • - Cervix and internal os: Normal, close • Blood pressure:115/83mmhg
- 44.
- 45. Goals of therapy •To prevent and treat clinical attack of malaria • to Completely eradicate the pparasite from the patient body • To reduce the human reservoir of infection cut down transmission to mosquito. • Prevention of Maternal Complications • Restoration of Normal Hemoglobin Levels
- 46.
- 47. COUNSELLING POINTS • Makesure the patient take medication correctly at the right time, right dose and duration. • Report any side effects noticed after taking the drugs • Advise patient to take nutritious food rich in iron such as vegetables and fruits. • Monitor fetal movements and inform healthcare providers if there are any changes in activity. • Patient should adhere to bed rest. Pharmacist intervation • There is a need of giving demethasone at this gestation age as the pneumocytes are well formed.this will help in the fatal lung maturation • Dose 6mg BD IM for 2 days. • Start Giving Intermittent Preventive Treatment(Sulfadoxine- pyrimethamine (500/25mg)