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close this bookGuidelines for the Treatment of Malaria (WHO; 2006; 266 pages) View the PDF document
View the documentGlossary
View the documentAbbreviations
open this folder and view contents1. Introduction
View the document2. The clinical disease
open this folder and view contents3. Treatment objectives
open this folder and view contents4. Diagnosis of malaria
open this folder and view contents5. Resistance to antimalarial medicines9
open this folder and view contents6. Antimalarial treatment policy
open this folder and view contents7. Treatment of uncomplicated P. Falciparum malaria10
close this folder8. Treatment of severe falciparum malaria14
View the document8.1 Definition
View the document8.2 Treatment objectives
View the document8.3 Clinical assessment
View the document8.4 Specific antimalarial treatment
View the document8.5 Practical aspects of treatment
View the document8.6 Follow-on treatment
View the document8.7 Pre-referral treatment options16
View the document8.8 Adjunctive treatment
View the document8.9 Continuing supportive care
View the document8.10 Additional aspects of clinical management
View the document8.11 Treatment during pregnancy
View the document8.12 Management in epidemic situations
View the document8.13 Hyperparasitaemia18
open this folder and view contents9. Treatment of malaria caused by P. vivax, P. ovale or P. malariae19
View the document10. Mixed malaria infections
open this folder and view contents11. Complex emergencies and epidemics
open this folder and view contentsAnnexes

8.13 Hyperparasitaemia18

18 Further information is provided in Annex 9.12

Patients with high parasite counts are known to be at increased risk of dying, although the relationship between parasite counts and prognosis varies at different levels of malaria endemicity. Many hyperparasitaemic patients have evidence of vital organ dysfunction but there is a large subgroup in which no other manifestations of severe disease are present. These patients have symptoms and signs compatible with a diagnosis of uncomplicated malaria in association with a high parasite count (sometimes termed uncomplicated hyperparasitaemia). The relevance for treatment is firstly the increased risk of progressing to severe malaria, and secondly the generally higher treatment failure rates. This is of particular concern as resistance to antimalarials is most likely to arise in patients with heavy parasite burdens and little or no immunity. In a low-transmission area in north-west Thailand, the overall mortality of uncomplicated falciparum malaria was 0.1%, but in patients with parasitaemia of >4% it was 3%. In areas of moderate or high transmission, much higher parasitaemias are often well tolerated, however. There is not enough evidence to provide a firm recommendation on the definition of hyperparasitaemia, although ≥5% parasitaemia in a low-transmission setting and ≥10% in a higher transmission setting are commonly used.

8.13.1 Treatment of hyperparasitaemia

Available evidence indicates that use of oral treatment under close supervision is effective in the treatment of patients with hyperparasitaemia who have no other features of severe malaria. Parenteral treatment should, however, be substituted at any time if there is concern. The rapidity of action of the artemisinin derivatives makes them ideal drugs. The standard treatment course should be given, as there is insufficient information on the safety of higher doses of the partner drug. Alternatively, the first dose of artemisinin derivative can be given parenterally or rectally to ensure adequate absorption, followed by a full course of ACT. Mefloquine-containing regimens in which the tablets are dispensed separately should be given such that mefloquine is given on days 2 and 3, rather than day 1, when it is better tolerated, with a lower incidence of early vomiting.

The optimum duration of treatment for hyperparasitaemia is still unresolved. Data to support the suggestion that patients should be treated conservatively with 7 days of an artemisinin derivative, plus a full course of partner medicine (e.g. artesunate 7 days + mefloquine 25 mg/kg bw divided over 2 days) are lacking. A longer ACT course than is recommended for uncomplicated malaria may not be possible in places where only fixed-dose combinations are available.

Summary of recommendations on the treatment of hyperparasitaemia in falciparum malaria



Hyperparasitaemic patients with no other signs of severe disease should be treated with oral artemisinin derivatives under the following conditions:

- patients must be monitored closely for the first 48 h after the start of treatment,

- if the patient does not retain oral medication, parenteral treatment should be given without delay.

O, E

Non-immune patients with parasitaemia of >20% should receive parenteral antimalarial treatment.



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