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Dr.dr.Suryadi N. N. Tatura, Sp.

A(K)

BAGIAN IKA FK UNIVERSITAS SAM RATULANGI/RSUP


PROF.DR. RD KANDOU MANADO
KOMISI AHLI DIAGNOSIS DAN TATALAKSANA
MALARIA
2 venomous snake 5 crocodile 8 jellyfish

1 3 scorpion 6 elephant 9 shark

4 big cats 7 hippopotamus 10 bear

World's Most Dangerous Animals


The World's Most
Dangerous
Anopheles mosquitoes transmit the malaria parasites
to ~550 million people worldwide each year,
resulting in more than 2 million deaths.

In 2008, malaria caused nearly 1 million deaths-mostly among children living


in Africa, where a child dies every 45 seconds of the disease .
DIAGNOSIS

KLINIS
Diagnosis
(AMI) Laboratory
(API)
Misused
AMT
Parasite stage

Differentiation :
Plasmodium sp Clinical
Manifestation

Imune status
Nutrition status
Genetic
Table 1. Durasi dan berat malaria

www.tulane.edu/~wiser/malaria/
Malaria Journal 2008, 7:186
Congenital malaria:
Parasite positive in cord blood
Malaria Parasite detected within 1 week after
delivery: neonate in endemic area
Malaria Parasite detected during first few
weeks of life: neonate in non-endemic area
With or without neonatal clinical manifestation
With or without history of maternal illness
during pregnancy or during delivery
MALARIA BERAT HANYA P.falciparum?
There are dangerous sign Severe illness with
Nuchal rigidity sign fever

Fever (anamnesis or
fever 37.5oC) MALARIA
DEMAM DAN
RDT positive
ATAU PUCAT
Fever(anamnesis or Fever without
fever 37.5o C) MALARIA
RDT negatif
Pemeriksaan tanda bahaya pada bayi
Tanyakan masalah bayi, usia, jenis kelamin, bb,
panjang dan keluhan.
Periksa tanda bahaya:
Tidak bisa makan/minum
Muntah
Kejang
Lethargy/penurunan kesadaran
There are dangerous sign Severe illness with
Nuchal rigidity sign fever

No common cold
No Measles
MALARIA
No other cause of fever
RDT positive
With common cold or Fever without
With measles or
Malaria
Other cause of fever
RDT negative
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7
There are dangerous sign Severe Illness with
Nuchal rigidity sign fever

No dengerous sign and no Fever:


nuchal rigidity Not MALARIA
DAERAH ENDEMIS RINGAN DAN SEDANG,
TANYAKAN DARI DAERAH ENDEMIS TINGGI
PX MALARIA
Management of MALARIA

Radical treatment

To kill all parasites

To kill all gametosit stage

Purpose : To cure all clinical manifestation and parasitologic


and break the transmission
- getting worse - getting worse
-- Parasite > 25 % -- Parasite +
-- Parasite +, Temp > 37.5 - getting worse
-- Parasite +
Getting worse
Mal + - getting worse
-- Parasite +,
-Temp > 37.5

H-2 H0 H2 H4 H14 H21


H-1 H1 H3 H5 H6 H7 H28

Hosp/Dr visit Start meds


- getting worse
-- Parasite +
- getting worse -Getting worse - getting worse
-- Parasite > -- Parasite +, Temp > 37.5 -- Parasite +

E.T.F = G.O.Dini L.T.F = G.O. Lambat

Monitoring the Response in Hospital or Clinic


CLASSIFICATION IN TREATMENT RESPONS ( WHO )

Kegagalan Pengobatan Dini - Berkembangnya menjadi malaria berat pada hari H1,
( ETF = Early Treatment Failure) H2, H3 disertai parasitemia
- Parasitemia pada H3 dengan temperatur aksiler>37.5C
- Parasitemia H2 > H0
- Parasitemia H3 >= 25% H0
Kegagalan Pengobatan Kasep - Berkembangnya tanda bahaya malaria berat setelah
( LCF = Late Clinical [& H3 dan parasitemia ( jenis parasit = H0)
Parasitological] Failure ) - Parasitemia dan temp. aksiler >37.5C pada H4 - H28

( LPF = Late Parasitological - Parasitemia H7, H14, H21, dan H28 ( Parasit = H0)
Failure )

Respon Klinis & Parasitologis - Tidak ada parasitemia sampai D28 dengan abaikan
Adekuat ( ACPR = Adequate temp. aksiler, tidak sesuai dengan kriteria ETF/
Clinical and Parasitological LCF/LPF.
Response)
CASE REPORT D-1
ID, ,SANGER, 10 yrs 5mo
Live in Mantehage

MANAGEMENT:
IVFD Nacl 0,45% in D-3
D5% (holiday segar)
67-68cc/hr= 22-23
gtt/minute

Injection Artesunate
1 x 60 mg ( Day III)

Paracetamol 3 x 300 D-4


mg (as needed)

Balance diuresis / 24
hours

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Early diagnosis and prompt effective treatment
within 24-48 of the onset of malaria symptoms
Rational use of antimalarials
reduce the spread of drug resistance, limit wastage, and
ensure effective case management of febrile illnesses.
Universal access to parasitological diagnosis (microscopy or
RDTs)
Combination therapy
improved efficacy; prevent or delay resistance
Appropriate weight-based dosing
prolong the useful therapeutic life of medicines,
Treatment of Malaria
Combination of Anti-malaria treatment (AMT)
Two or more AMT with same PK/PD with
different resistension.
Combination of AMT, should :
Safe and tolerated in any age
Effective and short acting
Resistent and/or no cross resistent
Available and cheap
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Anti Malaria pada Anak
Dosis
Lebih toleransi pada anak dibanding dewasa
Pada bayi: muntah> dewasa
Kontraindikasi
Tetracycline, doxycycline age <8y
Mefloquine BW < 5kg
Malarone, Artemisinin BW < 5kg
Pengobatan Malaria di Indonesia
Program nasional adalah derivat artemisin dengan golongan
aminokuinolin

Dihydroartemisinin dan Piperaquin


Tablet: 40 mg dihydroartemisinin dan 320 mg piperaquin
Per oral selama 3 hari

Artesunat-amodiakuin
2 blister (12 tablet): 50 mg artesunat dan 150 mg amodiaquin
Per oral selama 3 hari
3 blister (4 tablet): 50 mg artesunat dan 150 mg amodiaquin
Pengobatan Malaria tanpa komplikasi
Malaria falsifarum dan malaria vivax

Lini pertama : ACT + Primakuin

Dosis ACT malaria falsifarum sama dengan malaria vivax

Primakuin :
Malaria falsifarum : hanya hari pertama saja (0.75 mg/kgBB)
Malaria vivax : selama 14 hari (0.25 mg/kgBB)
Pengobatan Malaria tanpa komplikasi
Malaria falsifarum

Pengobatan Lini Pertama Malaria falsiparum menurut berat badan dengan


Dihydroartemisinin + Piperakuin (DHP) dan Primakuin

Dihydroartemisinin : 2-4 mg/kgBB


Piperakuin : 16-32 mg/kgBB
Primakuin : 0.75 mg/kgBB (untuk hari I)
Revised dosing of DHA+PPQ for young children
Children < 25kg treated with DHA+PPQ should receive
a minimum of 2.5mg/kg of DHA and 20mg/kg of PPQ
daily for 3 days.
Reducing transmissibility of falciparum infection
In low transmission areas, give a single dose of
0.25mg/kg primaquine with ACT to patients with P.
falciparum malaria (except pregnant women, infants <
6 months and women breastfeeding infants aged <6
months) to reduce transmission. G6PD testing is not
required.
The G6PD status of patients should be used to guide the
administration of primaquine for relapse prevention
Where status is unknown and G6PD testing is unavailable, the
decision to prescribe primaquine must be based on an assessment of
the risks and benefits of treating versus not treating
To prevent future relapse, treat people with vivax or ovale malaria (excluding
pregnant, infants aged <6months, women breastfeeding infants < 6 months of age,
and people with G6PD deficiency) with a 14-day course (0.25-0.5mg/kg daily) of
primaquine in all transmission settings.
In people with moderate G6PD deficiency, consider relapse prevention with
primaquine 0.75 mg base/kg once a week for 8 weeks under close medical
supervision.
In women who are pregnant or breastfeeding, consider weekly
chemoprophylaxis with chloroquine until delivery and breastfeeding is
complete, then treat with 14 days of primaquine to prevent future relapse.
Pengobatan Malaria tanpa komplikasi
Malaria falsifarum

Lini kedua: Kina + Doksisiklin atau


Tetrasiklin + Primakuin

Diberikan jika pengobatan lini pertama tidak efektif


Gejala klinis tidak memburuk tetapi parasit aseksual tidak berkurang
(persisten) atau timbul kembali (rekrudensi)
Doksisiklin dan tetrasiklin tidak dapat diberikan pada anak, sebagai gantinya
diberikan klindamisin dengan dosis 6 mg/kgBB/kali diberikan 3x sehari selama
7 hari
Pengobatan Malaria tanpa komplikasi
Malaria falsifarum

Pengobatan Lini Kedua Malaria falsifarum


(dengan obat kombinasi Kina & Doksisiklin)

Kina : 10 mg/kgBB/hari (3x per hari)


Primakuin : 0.75 mg/kgBB (untuk hari I)
Pengobatan Malaria tanpa komplikasi
Malaria vivax yang relaps

Dugaan relaps bila:


Pemberian primakuin dosis 0.25 mg/kgBB/hari sudah diminum
selama 14 hari namun penderita sakit kembali dengan parasit
positif dalam kurun waktu 3 minggu sampai 3 bulan setelah
pengobatan

Diberikan lagi regimen ACT yang sama tetapi dosis


primakuin ditingkatkan menjadi 0.5 mg/kgBB/hari
OBAT ANTI MALARIA (OAM)
Primakuin

Penderita defisiensi enzim G6PD ringan


Diberikan mingguan selama 8-12 minggu dengan dosis
mingguan 0.75 mg/kgBB
Bila gejala berlanjut, stop primakuin
Jika pemeriksaan G6PD tidak tersedia namun ada keluhan atau
riwayat warna urin coklat kehitaman setelah mium obat (gol.
Sulfa, primakuin, kina, klorokuin)
Primakuin sebaiknya tidak diberikan
Rujuk ke RS
Pengobatan Malaria tanpa komplikasi
Malaria ovale

Lini pertama malaria ovale


ACT (artemisinin-based combination therapy) yaitu
dihydroartemisinin-piperaquin (DHP) atau
artesunate-amodiaquin
Dosis sama dengan malaria vivax
Lini kedua malaria ovale
Sama dengan malaria vivax
Therapeutic objectives
Main objective is to prevent the patient from dying
Secondary objectives are to prevent disabilities and prevention
of recrudescent infection
Death from severe malaria often occurs within hours of
onset of symptoms or admission to hospital
Essential that therapeutic concentrations of a highly effective
antimalarial are achieved as soon as possible
Management of severe malaria comprises four main areas
Clinical assessment of patient
Specific antimalarial treatment
Additional treatments (managements of other complications),
and
Supportive care
Treat children and adults with severe malaria (including
infants, pregnant women in all trimester, and lactating
women) with intravenous or intramuscular artesunate for at
least 24 hours and until able to tolerate oral medication.
Once the patient has received at least 24h of parenteral
therapy, and can tolerate oral therapy, complete treatment
with 3 days of ACT
Children weighing <20 kg should receive a higher dose of
artesunate (3 mg/kg/dose) than larger children and adults
(2.4 mg/kg/dose) to ensure an equivalent drug exposure.
If parenteral artesunate is not available, use artemether in
preference to quinine for treating children and adults with
severe malaria
Pre-referral treatment
Where complete treatment of severe malaria is not
possible but injections are available, give children and
adults a single dose of intramuscular artesunate and
refer to an appropriate facility for further care.
Where intramuscular artesunate is not available use
intramuscular artemether or, if that is not available,
use intramuscular quinine
Where intramuscular injections are unavailable, treat
children <6 years with a single rectal dose (10mg/kg)
of artesunate, and refer immediately to an appropriate
facility for further care. Do not use rectal artesunate in
older children and adults.
Penatalaksanaan Malaria Berat
1. Pemberian obat anti malaria

Artesunat/artemeter
secara IV RS

Bila tidak memungkinkan


RUJUK KE RS RUJUKAN berikan dosis
artesunate/artemeter
lengkap secara IM
Artesunate/artemeter
secara IM (dosis awal) Puskesmas

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PAPUA BARAT: HB < 5 gr/dL
DAERAH ENDEMIS RINGAN SEDANG:
HB<7gr/dL
Slow infusion drips:
Normal saline atau D1/2 Saline 3-5
mL/kgbb/jam selama 3-4 jam dilanjutkan
dengan 2-3 mL/kgbb/jam
Penatalaksanaan Malaria Berat
1. Pemberian obat anti malaria

Artesunat diberikan 2.4 mg/kgBB (IV) sebanyak 3x


jam ke 0, 12, 24
Selanjutnya diberikan 2.4 mg/kgBB (IV) setiap 24
jam sampai penderita mampu minum obat
Dilanjutkan dengan regimen dihydroartemisinin-
piperaquin + primakuin atau ACT lainnya

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Penatalaksanaan Malaria Berat
1. Pemberian obat anti malaria (Obat alternatif)

Kina dihidroklorida parenteral


Kina per-infus merupakan obat alternatif malaria berat
untuk daerah yang tidak tersedia derivat artemisinin
parenteral
Tersedia dalam ampul kina dihidroklorida 25% (Satu
ampul berisi 500 mg/2 mL)

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Penatalaksanaan Malaria Berat
1. Pemberian obat anti malaria (Obat alternatif)

Dosis dan cara pemberian


Kina HCl 25% (per-infus) dosis 10 mg/kgBB (Bila umur <2
bulan : 6-8 mg/kgBB) diencerkan dengan D5% atau NaCl
0.9% sebanyak 5-10 ml/kgBB diberikan selama 4 jam
Diulang setiap 8 jam sampai penderita dapat minum obat
Selanjutnya diberikan kina per oral sampai 7 hari

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Penatalaksanaan Malaria Berat
1. Pemberian obat anti malaria (Obat alternatif)
Catatan pemberian Kina
Kina tidak boleh diberikan secara bolus IV toksik bagi jantung
menimbulkan kematian
Penderita dengan gagal ginjal dosis maintenance kina diturunkan
1/3 - 1/2 nya
Pada hari pertama pemberian kina oral, berikan primakuin dengan
dosis 0,75 mg/kgbb
Dosis kina maksimum dewasa : 2.000 mg/hari
Hipoglikemia dapat terjadi pada pemberian kina parenteral oleh
karena itu dianjurkan pemberiannya dalam Dextrose 5%

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Doctor, I would like to visit....

Do I need to take malaria tablet ??


Destination (rural/urban/forested area)
Duration of stay
Activity
Climate and season
Density of mosquito in specific area
The used of insect repellents and bed net
Malaria Risk
Prophylaxis AE
Ryan ET, et al. N Engl Med 2000;342:1716-25.
Pros
Reduce chance to get malaria 80-90%

Cons
Take risk to develop side effects
Not fully protected; limited efficacy against non-
falciparum malaria
May create false sense of safety
Need good compliance
Chloroquine-sensitive malaria:
Chloroquine
Chloroquine-resistant malaria
Mefloquine
Doxycycline
Atovaquone/proguanil
Mefloquine resistant malaria
Doxycycline
Atovaquone/proguanil
Terima kasih 79