Standard operating protocol for malaria management

Flowchart Algorithm

OPEN IN VIEWER Abbreviations: ACT: artemisinin-based combination therapy; IV: intravenous; RDT: rapid diagnostic test.

Severity assessment

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Clinical criteria Impaired consciousness: Glasgow coma scale <11 (Blantyre score <3 in children). Multiple convulsions: ≥2 seizures within 24 h. Prostration: Inability to sit, stand, or walk unassisted. Shock: Systolic BP <80 mmHg (<70 mmHg in children) with signs of poor perfusion (e.g. capillary refill ≥3 s, cool extremities). Pulmonary oedema: Respiratory rate >30/min with SpO2 < 92%, or radiological evidence. Spontaneous bleeding: Mucosal bleeding (gums, nose, or gastrointestinal tract) or venepuncture sites.

Laboratory criteria Hypoglycaemia: Plasma glucose <2.2 mmol/L (<40 mg/dL). Severe anaemia: Haemoglobin <70 g/L or haematocrit <20% (≤50 g/L or ≤15% in children <12 years) plus parasite density >10,000/μL. Jaundice: Bilirubin >50 μmol/L (>3 mg/dL) plus parasite density >100,000/μL. Renal impairment: Creatinine >265 μmol/L (>3 mg/dL) or urea >20 mmol/L (AKI- KDIGO criteria in children) Acidosis: Bicarbonate <15 mmol/L, base deficit >8, or lactate ≥5 mmol/L. Hyperparasitaemia: >10% parasitaemia.

N.B.: A single clinical or laboratory criterion is sufficient for diagnosing severe malaria. Hyperparasitaemia alone is not sufficient to define severe malaria unless accompanied by organ dysfunction, but it warrants close monitoring owing to high risk of progression to severe malaria. ¹

Abbreviations: AKI: acute kidney injury; BP: blood pressure; KDIGO: Kidney Disease: Improving Global Outcomes.

Treatment of malaria

First-line: ACT for 3 days (irrespective of Plasmodium species)

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ACT	Dosage (body weight based)			Preferred/Avoid in
Artemether-Lumefantrine (AL)	Weight (kg)	Dose (mg) bd		Wide availability. Preferred in: most settings (including in 1st trimester of pregnancy*).
	<15	20 + 120
	15 to <25	40 + 240
	25 to <35	60 + 360
	≥35	80 + 480
Artesunate + Amodiaquine (AS + AQ)	Weight (kg)	Dose (mg) od		Avoid in: Persons with HIV receiving zidovudine or cotrimoxazole (severe neutropenia risk), or efavirenz (hepatotoxicity risk).
	<9	25 + 67.5
	9 to <18	50 + 135
	18 to <36	100 + 270
	≥36	200 + 540
Artesunate + Mefloquine (ASMQ)	Weight (kg)	Dose (mg) od		Avoid in: severe malaria as a follow-on oral ACT due to the risk of neuropsychiatric effects.
	<9	25 + 55
	9 to <18	50 + 110
	18 to <30	100 + 220
	≥30	200 + 440
Artesunate + Sulphadoxine-Pyrimethamine (AS + SP)	Weight (kg)	AS (mg) od	SP (mg) single dose	Avoid in: 1st trimester pregnancy (antifolate toxicity), patients on cotrimoxazole (additive antifolate toxicity), and areas with high SP resistance.
	<10	25	250/12.5
	10 to <25	50	500/25
	25 to <50	100	1000/50
	≥50	200	1500/75
Dihydro-artemisinin + Piperaquine (DHAP)	Weight (kg)	Dose (mg) od		Avoid in: Patients with congenital QT prolongation, or those receiving QT-prolonging drugs.
	<8	20 + 160
	8 to <11	30 + 240
	11 to <17	40 + 320
	17 to <25	60 + 480
	25 to <36	80 + 640
	36 to <60	120 + 960
	60 to <80	160 + 1280
	≥80	200 + 1600

*Pregnancy (1^st trimester): 1^st line: AL; Alternatives: AS + AQ, ASMQ, or DHAP; Avoid: AS + SP.

Alternative: Chloroquine may be used for uncomplicated non-falciparum malaria only in areas with confirmed chloroquine sensitivity.

Dose: 25 mg/kg base over 3 days. Adults: 600/600/300 mg on days 1/2/3; Children: 10/10/5 mg/kg on days 1/2/3.^1–3

B. Severe malaria (irrespective of Plasmodium species)

First-line: IV artesunate (give IM if IV access is not feasible).

Applicable to: All age groups, including pregnant women (all trimesters) and children.

Dose: 2.4 mg/kg at 0, 12, and 24 h, then od. If body weight <20 kg: 3.0 mg/kg per dose.

Switch to oral: Continue IV therapy for at least 24 h. Once the patient can tolerate orally, complete the treatment with a 3-day ACT course.

Alternatives (if artesunate unavailable): IM artemether (preferred) or IV quinine.

Supportive management

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Cerebral malaria	Maintain airway; intubate if needed. Avoid steroids.
Convulsions	IV/IM lorazepam, midazolam, or diazepam.
Hypoglycaemia	Dextrose bolus, then maintenance infusion.
Severe anemia	Transfusion if haemoglobin <50 g/L or haematocrit <15%. Exchange transfusion is not routinely recommended.
Renal failure	Judicious IV fluids; avoid fluid overload. Dialysis if oliguria persists.
Fever >38.5°C	Paracetamol 10–15 mg/kg 4–6 h (max 4 g/d in adults). Avoid non-steroidal anti-inflammatory drugs.
Empirical antibiotics	If sepsis is suspected or shock persists despite antimalarials.

Flowchart Algorithm: Primaquine Use

OPEN IN VIEWER N.B.: Tafenoquine (single-dose) may be used for radical cure only if G6PD activity is ≥70% (quantitative testing required). Radical cure is contraindicated in pregnancy and breastfeeding; weekly chloroquine prophylaxis should be used until primaquine is permissible. Contraindiactions: Primaquine: Pregnancy; breastfeeding if infant <1 month; or infants aged <1 month. Tafenoquine: Pregnancy; breastfeeding; children <2 years; or G6PD activity <70%. G6PD: glucose-6-phosphate dehydrogenase.