This week's recommended reading is the article "Review of UK malaria treatment guidelines 2016 (Public Health England Advisory Committee on Malaria Prevention)", published at the beginning of May on the Archives of Disease in Childhood. Education and Practice Edition.
SUMMARY: This guideline, written by the Public Health England Advisory Committee on Malaria Prevention (PHE ACMP) in 2016, in line with WHO guidelines, covers the diagnosis and management of malaria. Malaria is the most common imported tropical pathogen in the UK, and children comprise about 10% of the 1300–1800 UK cases per annum. Plasmodium falciparum (P. falciparum) is the most common agent and is associated with more severe disease. This guideline replaces the previous PHE ACMP UK malaria treatment 2007 guideline. The authors reported the main points of this guideline.
Malaria should be considered in any unwell or feverish child, who has visited an endemic country, regardless of whether prophylaxis was taken. The time of infection presentation could widely vary from 6 days to a year post-travel.
Malaria in children can be notoriously non-specific, even without fever. Thrombocytopenia is a common manifestation.
Thick and thin blood films remain the gold diagnostic standard, but rapid diagnostic tests are almost as accurate for P. falciparum and P. vivax. If there is clinical suspicion with negative blood films, these should be repeated at 12–24 hours and again after a further 24 hours.
Even in uncomplicated malaria, there can be rapid deterioration during the first 24 hours of treatment, so admission is recommended initially. Uncomplicated P. falciparum malaria should be treated with oral artemisinin combination therapy (ACT).
Severe malaria (defined as the presence of the following manifestations: cerebral involvement, respiratory distress/metabolic acidosis, severe anemia, prostration, hypoglycemia, electrolyte disturbance, circulatory shock) should be managed in a pediatric intensive care or high dependency unit with advice from a pediatric infectious diseases specialist with malaria expertise.
Intravenous artesunate gives a clear survival advantage over quinine and is the drug of choice.
Fluid resuscitation should be cautious, even in the context of shock. Glucose monitoring is crucial, and broad-spectrum antibiotics should be given, until bacterial coinfection is excluded.
For non-P. falciparum malaria, both ACT and chloroquine are effective for acute infection, although there is growing resistance to chloroquine in some Indonesian areas. To prevent relapse for P. vivax and P. ovale, primaquine treatment should overlap with ACT to ensure eradication of hypnozoites in the liver.
All children receiving intravenous artesunate need a repeat full blood count at 2 weeks post-therapy as it is associated with delayed hemolysis.
Family of infected children should be given information about malaria, and how to prevent and manage it.
All malaria cases should be notified to PHE.
The authors concluded reporting unresolved controversies: 1) the potential management of uncomplicated malaria as an outpatient, as it is probably better to hospitalized children, at least 24 hours, due to the risk of rapid deterioration and vomiting ACT; 2) how many films to perform to exclude malaria; 3) definition of severe malaria in non-endemic countries, as the WHO guideline has a more extensive list of severity features, whose relative importance in the non-endemic setting remains unclear.
AUTHORS: Evans C., Fitzgerald F., Cunnington A.
Click here to go to the article.