Diagnosis Dini dan Penatalaksanaan Malaria
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Transcript of Diagnosis Dini dan Penatalaksanaan Malaria
MALARIAMALARIA ESSENTIALS OF DIAGNOSISESSENTIALS OF DIAGNOSIS HISTORY OF EXPOSURE IN A MALARIA-ENDEMIC HISTORY OF EXPOSURE IN A MALARIA-ENDEMIC
AREAAREA PERIODIC ATTACTS OF SEQUENTIAL CHILLS, FEVER PERIODIC ATTACTS OF SEQUENTIAL CHILLS, FEVER
& SWEATING, APYREXIA& SWEATING, APYREXIA HEADACHE, MYALGIA, SPLENOMEGALI, ANEMIA, HEADACHE, MYALGIA, SPLENOMEGALI, ANEMIA,
LEUKOPENIALEUKOPENIA PARASITES IN RBC, IDENTIFIED IN THICK OR THIN PARASITES IN RBC, IDENTIFIED IN THICK OR THIN
BLOOD FILMSBLOOD FILMS
ETIOLOGY : ETIOLOGY : SPOROZOA GENUS SPOROZOA GENUS
PLASMODIUMPLASMODIUMPlasmodia malaria :Plasmodia malaria : Pl. vivax Pl. vivax Mal. tertiana benigna Mal. tertiana benigna Pl. ovale Pl. ovale Mal. ovale / T. benigna Mal. ovale / T. benigna Pl. falsiparum Pl. falsiparum Mal. tropika / T. maligna Mal. tropika / T. maligna Pl. malariae Pl. malariae Mal. Kuartana Mal. Kuartana P. knowlesi ( dahulu menginfeksi binatang, P. knowlesi ( dahulu menginfeksi binatang,
demam tiap hari) demam tiap hari) perbatasan dgn perbatasan dgn MalaysiaMalaysia
Life cycle of malaria Life cycle of malaria parasitesparasites
P falciparum life cycleP falciparum life cycle
LIFE CYCLE OF MALARIA PARASITESLIFE CYCLE OF MALARIA PARASITESEE I
EE II
Exoerytrocyter & RBC phase Exoerytrocyter & RBC phase of Pl. malariaof Pl. malaria
Pl. vivaxPl. vivaxEE II (+)EE II (+)
Pl. ovalePl. ovale EE I (+) EE I (+)
Pl. falcifarumPl. falcifarum EE II (-) EE II (-)
Pl. malariaePl. malariae
EE II: HeparEE II: Hepar EE I : Dlm darah menuju ke hati EE I : Dlm darah menuju ke hati
PATHOGENESIS (1) XXX THE ASEXUAL ERYTHROCYTIC IS RESPONSIBLE FOR THE
SYMPTOMS:
- FEVER, HEADACHE, NAUSEA & MUSCULAR PAIN
AT THE TIME SCHIZONTINFECTED RBC RUPTURE
- ENDOGENEOUS PYROGEN (INTERLEUKIN-1) AND
MEDIATORS (KININS & CATHECTIN (TNF) RELATED
TO PATHOGENESIS?
PATHOGENESIS (2) XXX * ENCEPHALOPATHY:
~ RBC CONTAINING SCHIZONTS & MALARIAL
PIGMENT OBSTRUCT CEREBRAL CAPILLARIES &
VENULES
~ CEREBRAL EDEMA MAY DEVELOP AS A RESULT
OF AGONAL HYPOXIA
~ SEQUESTRATION OF PARASITIZED RBC IN BRAIN
& OTHER TISSUE RESULT FROM CYTOADHERENCE
OF KNOBLIKE PROTUBERANCE ON THE RBC TO
ENDOTHELIUM
PATHOGENESI (3) XXX
~ DECREASED DEFORMITY OF INFECTED RBC
SLUGGISH MICROVASCULAR FLOW
~ CEREBRAL ANAEROBIC GLYCOLYSIS & REDUCED
CEREBRAL OXYGEN TRANSPORT CEREBRAL
MALARIA
PATHOGENESIS (4) XXX
- ANEMIA:~ HEMOLYSIS OF INFECTED RBC~ RAPID SPLENIC REMOVAL ON NONPARASITIZED
ERYTHROCYTES~ DYSERYTHROPOISIS
- THROMBOCYTOPENIA SEQUESTRATION IN THE SPLEEN
PATHOGENESIS (5) XXX
- ACUTE RENAL FAILURE
ACUTE TUBULAR NECROSIS
ISCHEMIA RESULTING FROM:
~ HYPOVOLEMIA
~ RENAL VASOCONTRICTION
~ MICROVASCULAR OBSTRUCTION:
* PARASITIZED RBC
* PIGMENT NEPHROPATHY SECONDARY
TO HEMOLYSIS
ACUTE RENAL FAILURE
Diagnosis malariaDiagnosis malaria• Ada riwayat demam sebelumnya 3 Ada riwayat demam sebelumnya 3
harihari• Tidak ada penyebab yang lainTidak ada penyebab yang lain• Ada gambaran klinis: Ada gambaran klinis: Dingin Dingin Demam Demam
Keringat -- Apireksia Keringat -- Apireksia • Ditemukan adanya anemiaDitemukan adanya anemia• Diagnosis parasitologis semestinya sdh ada Diagnosis parasitologis semestinya sdh ada
dalam wkt < 2 jamdalam wkt < 2 jam– Light microscopicLight microscopic– RDT (Rapid Diagnostic Test )RDT (Rapid Diagnostic Test )
PATHOGENESIS (6) XXX•THE SPLEEN IS LARGE:
~ ENGORGE & HEAVILY PIGMENTED
~ CONTAINING MANY PHAGOCYTIC CELLS
INGESTED RBC & MALARIAL PIGMENT
* EDEMATOUS LUNGS:
~ PULMONARY CAPILLARIES & VENULE ARE
PACKED WITH INFLAMMATORY CELLS
~ ENDOTHELIAL & INTESTINAL EDEMA
Pembesaran Lien menurut Pembesaran Lien menurut HackettHackett
Pembesaran Lien menurut Pembesaran Lien menurut SchuffnerSchuffner
CLINICAL FINDINGS (1)A. SYMPTOMS (1)
- SHAKING CHILLS (THE COLD STAGE)
- FEVER (THE HOT STAGE) ≥41ºC
- DIAPHORESIS (THE SWEATING STAGE)
- FATIGUE
- HEADACHE
- DIZZINESS
- MYALGIA
- ARTHRALGIA
- BACKACHE
- DRY COUGH
DINGIN DEMAM
APIREKSI KERINGAT
DI-DE-RI-TA
KASUS MALARIAKASUS MALARIA Kasus tanpa komplikasiKasus tanpa komplikasi Malaria berat atau malaria dengan Malaria berat atau malaria dengan
komplikasikomplikasi Kasus Rujukan ke rumah sakitKasus Rujukan ke rumah sakit
Kasus tanpa komplikasiKasus tanpa komplikasi Mesti dibedakan dengan:Mesti dibedakan dengan:
– Demam tifoidDemam tifoid– Demam dengueDemam dengue– Infeksi saluran napas akutInfeksi saluran napas akut– Leptospirosis ringanLeptospirosis ringan– Infeksi virus yang lain Infeksi virus yang lain
Demam tifoidDemam tifoid1.1. Demam sore/malam hari (naik Demam sore/malam hari (naik
perlahan-lahan)perlahan-lahan)2.2. Lidah tifoidLidah tifoid
- Kering di lidahaKering di lidaha- TremorTremor- Pinggir hiperemisPinggir hiperemis- Di tengah kotor ke abu-anuanDi tengah kotor ke abu-anuan
3.3. Nyeri tekan kanan bawah > kiri bawahNyeri tekan kanan bawah > kiri bawah
Demam berdarah dengueDemam berdarah dengue1.1. Gangguan gastrointestinalGangguan gastrointestinal2.2. Mata: - hiperemis, rasa nyeri Mata: - hiperemis, rasa nyeri
retroorbitalretroorbital3.3. Demam datang tiba-tiba langsung Demam datang tiba-tiba langsung
tinggitinggi4.4. --------------5.5. Demam Demam baru rasa dingin baru rasa dingin
Malaria berat atau malaria Malaria berat atau malaria dengan komplikasidengan komplikasi
Perlu dibedakan dengan infeksi lainPerlu dibedakan dengan infeksi lain Radang otak (meningitis, ensefalitis)Radang otak (meningitis, ensefalitis) Stroke (gangguan serebrovaskuler)Stroke (gangguan serebrovaskuler) Tifoid ensefalopatiTifoid ensefalopati HepatitisHepatitis Leptospirosis beratLeptospirosis berat Glomerulonefritis akut atau kronisGlomerulonefritis akut atau kronis SepsisSepsis DBD atau dengue shock syndrome/DSSDBD atau dengue shock syndrome/DSS
Kasus Rujukan ke rumah Kasus Rujukan ke rumah sakitsakit
– Semua kasus berat atau berkomplikasi Semua kasus berat atau berkomplikasi segera dirujuk ke rumah sakitsegera dirujuk ke rumah sakit
– Semua kasus ringan yang sulit diatasiSemua kasus ringan yang sulit diatasi
Gejala klinis pokok Gejala klinis pokok malaria adalahmalaria adalah
– A. Menggigil/rasa dingin menyusul (1)A. Menggigil/rasa dingin menyusul (1)– B. Demam, menyusul (2)B. Demam, menyusul (2)– C. Kerkeringat banyak, menyusul (3)C. Kerkeringat banyak, menyusul (3)– ApireksiaApireksia
A-C disebutA-C disebut trias malaritrias malari
Klinis Malaria Klinis Malaria TRIAS MALARIA TRIAS MALARIA KOPAPDIKOPAPDI
DIDINGIN DNGIN DEEMAMMAM
((TATA)APIREKSI KE)APIREKSI KERIRINGATNGAT
DI-DE-RI-TADI-DE-RI-TA
Tanda klinis/ Trias Tanda klinis/ Trias Malaria/WHOMalaria/WHO
1. Anemis1. Anemis
2. Splenomegali2. Splenomegali
3. DIDERITA/ Trias KOPAPDI3. DIDERITA/ Trias KOPAPDI
Anemia• Pengrusakan eritrosit o/ parasit baik eritrosit yang terinfeksi parasit maupun tidak • Terjadi hambatan eritropoesis sementara • Hemolisis karena proses complement mediated immune system• Eritrofagositosis• Penghambatan pengeluaran retikulosit
Anemia pd P. falcifarum : suatu mekanisme multifaktorial dengan elemen destruksi meningkat & delektif produksi eritrosit
Pd pasien ini anemia jg diperberat: kehamilan & partus
Prosedur pasca perawatan Prosedur pasca perawatan kasuskasus
– Pada malaria Pada malaria tertianatertiana di luar rumah sakit di luar rumah sakit
masih harus minum masih harus minum primakuinprimakuin selama selama 1515 hari hari
– Pada malaria Pada malaria tropikatropika umumya sembuh umumya sembuh
sempurna, kecuali ada sekuelae dari sempurna, kecuali ada sekuelae dari
komplikasikomplikasi
Malaria berat (salah Malaria berat (salah satunya)satunya)
Tanda-tanda Laboratorium1. Gangguan kesadaran ringan (GCS <15) malaria serebral
7. Anemia berat (Hb < 5 gr% atau hematokrit <15%
2. Kelemahan otak (tidak bisa duduk/berjalan) tanpa kelainan neurologik
8. Pada hitung parasit 10.000/µL
3. Kejang-kejang 9. Asidemia asidosis?4. Perdarahan spontan 10. Makroskopik
hemoglobinuri5. Gagal ginjal akut: urine <400ml / 24 jam
11. Hiperparasitemia >5%
6. Hiperpireksia (suhu rektal >400C)
12. Ikterus (kadar bilirubin darah > 3 mg%)
BEDA MALARIA BERAT PADA DEWASA & ANAKBEDA MALARIA BERAT PADA DEWASA & ANAK
A N A K DEWASA
Batuk Sering JarangKejang Sangat sering SeringIkterik Jarang SeringLama sakit Pendek (1-2 hr) Panjang (5-7 hr)Lama koma Pendek (1-2 hr) Panjang (2-4 hr)Hiperparasitemia Sering JarangHipoglikemia Sering sebelum Rx Sering sesudah Rx/hmlGagal ginjal Jarang SeringTek.I.K naik Sering/naik Jarang/ normalEdema paru Jarang SeringPerdarahan Jarang 10 %Ggn brain stem Lebih sering JarangSequelae Neuro. > 10 % < 5 %
BEDA MALARIA BERAT PADA ANAK DAN BEDA MALARIA BERAT PADA ANAK DAN DEWASADEWASA
Items Anak DewasaBatuk Sering JarangKejang Sangat sering SeringIkterik Jarang SeringLama sakit Pendek (1-2 hr) Panjang (5-7 hr)Lama koma Pendek (1-2 hr) Panjang (2-4 hr)Hiperparasitemia Sering Jarang
Hipoglikemia Sering sebelum Rx Sering sesudah Rx/hml
Gagal ginjal Jarang SeringTek.I.K naik Sering naik Jarang/normalEdema paru Jarang SeringPerdarahan Jarang 10%Ggn brain stem Lebih sering JarangSequelae Neuro. > 10% < 5%
SEVERE MALARIASEVERE MALARIA
DEFINITION : Patient, Plasmosium Asexual parasitemia,with one or more CLINICAL or LABORATORY FEATURES :
PROSTRATIONIMPAIRED CONSCIOUSNESSRESPIRATORY DISTRESSMULTIPLE CONVULSIONSCIRCULATORY COLLAPSEPULMONARY EDEMAABNORMAL BLEEDINGJAUNDICEHAEMOGLOBINURIA
SEVERE ANAEMIAHYPOGLYCAEMIAACIDOSISRENAL IMPAIRMENTHYPERLACTATAEMIAHYPERPARASITEMIA
WHO: Guidelines for the Treatment of Malaria 2006
CLINICAL FINDNGS (2)
SYMPTOMS (2)
- GASTROINTESTINAL SYMPTOMS:
~ ANOREXIA
~ NAUSEA
~ VOMITING
~ DIARRHEA
~ ABDOMINAL CRAMPS
CLINICAL FINDINGS (3)
SYMPTOMS (3)
-THE ATTACKS PERIODICITY:
~ EVERY-DAY FALCIPARUM
~ EVERY-OTHER-DAY TERTIAN PL. VIVAX & OVALE
~ EVERY-THIRD-DAY QUARTIAN PL. MALARIAE
~ TIRED BETWEEN ATTACKS, BUT FEELS WELL
~ AFTER THIS PRIMARY EPISODE, RECURRENCE ARE
COMMON, EACH SEPERATED BY A LATENT PERIOD
CLINICAL FINDINGS (4)
SIGNS
- SPLENOMEGALY:
APPEAR ACUTE SYMPTOMS
CONTINUED ≥4 DAYS
- MILDY HEPATOMEGALY
- ANEMIA
COMPLICATIONS (1):1. CEREBRAL MALARIA:
- HEADACHE
- MENTAL DISTURBANCES
- NEUROLOGIC SIGNS
- RETINAL HEMORRHAGES
- CONVULSIONS
- DELIRIUM
- COMA
COMLICATIONS (2):
2. HYPERPYREXIA
3. HEMOLYTIC ANEMIA
4. NONCARDIOGENIC PULMONARY EDEMA
5. ACUTE TUBULAR NECROSIS & RENAL
FAILURE BLACKWATER FEVER DUE TO
>QUININE TREATMENT
COMPLICATIONS (3)6. ACUTE HEPATOPATHY MARKED
JAUNDICE, BUT NO LIVER FAILURE
7. HYPOGLYCEMIA
8. ADRENAL INSUFFICIENCY-LIKE SYNDROME
9. CARDIAC DYSRHYTHMIAS
10, GASTROINTESTINAL SYNDROMES
11. LACTIC ACIDOSIS & HYPOGLYCEMIA
12. PNEUMONIA
13. WATER & ELECTROLYTE IMBALANCE
Plasmodium Falciparum>>, Vivax, Knowlesi dapat menyebabkan Malaria Berat
Kematian10 – 50 %
2-- 6%
Malaria cerebral salah satu komplikasi malaria terberat,
berlangsung progresif
Plasmodium falciparum
25-50%
Kematian
P. Vivax P. Malariae
P. Falciparum
Pasien malaria.. Menggigil, berselimut lengkap
400 GigitanNyamuk
200 Meng-infeksi
Manusia
100 MalariaKlinis
2 – 6 %Malaria Berat
Syndromes of severe malaria: Syndromes of severe malaria: XXXXXX
2. non-immune adults2. non-immune adultsMultiorgan failure:Multiorgan failure:
– Hyperparasitemia Hyperparasitemia – Acute renal failureAcute renal failure– JaundiceJaundice– Metabolic acidosisMetabolic acidosis– HypoglycemiaHypoglycemia– Acute respiratory Acute respiratory
distress syndromedistress syndrome– Anemia/Anemia/
thrombocytopeniathrombocytopenia– Cerebral malariaCerebral malaria
Extensi pada malaria cerebral
8 hours after admission
24 hoursafter admission
Ikterik & Cerebral
Malaria cerebral , jaundice, in Manado General Hospital
Purpura ( perdarahan dibawah kulit, pada malaria dengan trombosit 2000/ mm3
Ny. S 36 tahunSuku Makassar
Alamat :Limbung, Sungguminasa GowaPekerjaan:ibu rumah tangga
masuk rumah sakit:Labuang Baji 03 September 2007 (reg. No.122153)
Apusan darah Tepi : Gambaran anemia hemolitik ec. Plasmodium falsiparum
EKG: dalam batas normal
Jawaban konsul subdivisi infeksi tropis Kesan: malaria cerebral Usul: Pemberian Kina intravena
Hasil Konsul Sub Divisi Hematologi-Onkologi Medik
Kesan : Anemia hemolitik belum dapat disingkirkanUsul : pemeriksaan bilirubin indirek, Coomb test, LDH, Retikulosit
Parameter Laboratorium
HARI 1 HARI 3 HARI 4
HARI 5
HARI 6
HARI 10
LeukositHbEritrositHematokritTrombositGDSUreum KreatininSGOTSGPTWidal DDR
3.9003.0-
10.267.00
0124
51005,7
2.14518,1
61.000
176231.92.0710447(-)(-)
-----------
(-)
1.500
7.0--
400085------
------
19.261.1----
5.7007.5
2.490-
179.000-
37.50.41
----
Parameter Laboratorium
HARI 1 HARI 3 HARI 4
HARI 5
HARI 10
LeukositHbEritrositHematokritTrombositGDSUreum KreatininSGOTSGPTWidal DDR
3.9003.0-
10.267.00
0124
51005,7
2.14518,1
61.000
176231.92.0710447(-)(-)
-----------
(-)
1.500
7.0--
400085------
5.7007.5
2.490-
179.000-------
MANAGEMENT: XXXA. TREATMENT OF ACUTE ATTACKS:
UNCOMPLICATED : SYMPTOMATIC WITHOUT SIGNS OF SEVERITY OR UNCOMPLICATED : SYMPTOMATIC WITHOUT SIGNS OF SEVERITY OR EVIDENCE OF VITAL ORGAN DYSFUNCTIONEVIDENCE OF VITAL ORGAN DYSFUNCTION (1)
1. ELIMINATION OF ASEXUAL ERYTHROCYTIC PARASITES
- CHLOROQUINE PHOSPHATE (SALT) 1G AT
0, 24, AND THEN 0.5 G AT 48 HOURS
HOURS 0 24 48
CHLOROQ/ GR 1 1 0.5 - MEFLOQUINE,
~ 1 x 250 MG FOR 3 DAYS, OR 750-1250 MG,
THEN 500 MG AFTER 6-8 HOURS
TREATMENT OF ACUTE ATTACKS (2) XXX
- QUININE SULFATE (PLUS DOXYCYCLINE, CLINDAMYCIN,
OR FANSIDAR
- ATOVAQUONE 250 MG (PLUS DOXYCYCLINE 100 MG OR
PROGUANIL 100 MG)
- HALOFANTRINE,
- ARTEMISININ (QINGHAOSU), FISRT DAY 2X2 TABS,
THEN 2X1 TABLET FOR 5 DAYS
TREATMENT OF ACUTE ATTACKS (3) XXX
IN SEVERE PATIENTS
- START ORAL THERAPY WITH CHLOROQUINE
AS SOON AS POSSIBLE
- IV QUININE DIHYDROCHLORIDE
- QUINIDINE GLUCONATE
- PARENTERAL CHLOROQUINE
TREATMENT OF ACUTE ATTACKS (4) XXX
2. ERADICATION OF P. VIVAX OR P. OVALE
CHLOROQUINE AS ABOVE FOLLOWED BY 0.5 G ON DAYS 10
AND 17 PLUS PRIMAQUINE PHOSPHATE, 25,3 MG (SALT)
DAILY FOR 14 DAYS STARTING ABOUT DAY 4
DAYS 1 2 3 4 10 17
CHLOROQ/G 1.0 1.0 0.5 ↓ 0.5 0.5
PRIMAQUINE 26.3 FOR 14 DAYS
TREATMENT OF ACUTE ATTACKS (5) XXX
3. ELIMINATION OF PERSISTENT GAMETOCYTEMIA
- CHLOROQUINE FOR P.VIVAX, P. OVALE,
P. MALARIAE
- PRIMAQUINE SALT, SINGLE DOSE, 26.3 MG
FOR P. FALCIPARUM
TREATMENT OF ACUTE ATTACKS (6) XXX
* TREATMENT OF FALCIPARUM MALARIA ACQUIRED
IN AREAS WHERE P. FALCIPARUM IS RESISTANT TO
CHLOROQUINE (1)
- START WITH ORAL QUININE SULFATE, 10 MG/KG 3X
DAILY FOR 3-7 DAYS, PLUS :
~ DOXYCYCLINE, 2X100 MG FOR 7 DAYS
~ CLINDAMYCIN. 3X900 MG DAILY FOR 5 DAYS
~ PYRIMETHAMINE, 2X25 MG DAILY FOR 3 DAYS
~ SULFADIAZINE, 4X500 MG DAILY FOR 7 DAYS
~ 3 TABLETS OF FANSIDAR (PYRIMETHAMIN+
SULFADOXINE)
TREATMENT OF ACUTE ATTACKS (7) P. FALCIPARUM IS RESISTANT TO CHLOROQUINE (2).
- ALTERNATIVE DRUGS ARE:
~ MEFLOQUINE
~ HALOPHANTRINE
~ ARTESUNATE
~ ATOVAQUONE
- SEVERELY ILL:
~ IV QUININE OR QUINIDINE
~ DOCYCYCLINE OR CLINDAMYCIN PARENTRALLY - ORAL TREATMENT WITH QUININE PLUS THE ANTIBIOTIC SHOULD BE AS SOON AS POSSIBLE - ARTESUNATEARTESUNATE++CLINDAMYCINECLINDAMYCINE //AZYTHROMICINEAZYTHROMICINE PREGNANT PREGNANT WOMAN & WOMAN & CHILDRENCHILDREN
TREATMENT OF ACUTE ATTACKS (8) * SPECIAL TREATMENT FOR TREATMENT OF SEVERE P. FALCIPARUM MALARIA (1) - MEDICAL EMERGENCY THAT REQUIRES:
~ HOSPITALIZATION~ INTENSIVE CARE~ IV CHEMOTHERAPY AS RAPID AS POSSIBLE~ REQUIRING >48 HOUR OF PARENTRAL THERAPY~ DEHYDRATION SHOULD BE DONE WITH CAUTION~ FLUID, ELECTROLYTE & ACID- BASE BALANCE
MUST BE MONITORED~ ArtesunateArtesunate + + Clindamycine Clindamycine / /AzytromicineAzytromicine
pregnant womanpregnant woman & & childrenchildren..
Di hidro artemicinine (DHA) plus Pipeaquine: Di hidro artemicinine (DHA) plus Pipeaquine: Artekin or Duo-cotexin (nearly recommended by Artekin or Duo-cotexin (nearly recommended by WHO.WHO.
TREATMENT OF ACUTE ATTACKS (9)* SPECIAL TREATMENT FOR TREATMENT OF
SEVERE P. FALCIPARUM MALARIA (2): ~ EARLY DIALYSIS MAY BE NECESSARY FOR RENAL
FAILURE
~ BLOOD GLUCOSE LEVELS SHOULD BE MONITORED
EVERY 6 HOURS IF HYPOGLYCEMIA +,
- 50% DEXTROSE, 1-2 ML/KG
- MAINTENANCE 5-10% DEXTROSE
TREATMENT OF ACUTE ATTACKS (10)* SPECIAL TREATMENT FOR TREATMENT OF SEVERE
P. FALCIPARUM MALARIA (3)
- DIC FRESH WHOLE BLOOD
- HCT < 20% TRANSFUSION
- EXCHANGE TRANSFUSION WHEN >15% RBC
ARE PARASITIZED
- SEIZURES ANTICONVULSANTS
- TEMPERATURE IS MAINTAINED <38.5 ºC
- BLOOD FILM SHOULD BE CHECKED DAILY UNTIL
PARASITEMIA CLEARS; WEEKLY THEREAFTER
FOR 4 WEEKS RECRUDESCENCE?
B. CHEMOPROPHYLAXIS (1)
a. IN REGIONS WHERE P. FALCIPARUM AND P. VIVAX
ARE SENSITIVE TO CHLOROQUINE
~ DRUG OF CHOICE
1. CHLOROQUINE PHOSPHATE, 500 MG WEEKLY, ONE
WEEK BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4-6 WEEK AFTER LEAVING
CHEMOPROPHYLAXIX (2) ~ ALTERNATIVE DRUGS
1. HALOFANTRINE.
2. FANSIDAR
3. AMODIAQUINE.
4. PYRIMETHAMINE
5. ARTEMISININ
6. PROGUANIL
7. QUININE
CHEMOPROPHYLAXIX (3)b. IN REGIONS WHERE P. FALCIPARUM IS RESISTANT
TO CHLOROQUININE
~ DRUGS OF CHOICE
1. MEFLOQUINE SALT, 250 MG (228 MG BASE) WEEKLY,
2 WEEKS BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING.
CHEMOPROPHYLAXIX (4) ~ ALTERNATIVE:
- 1. DOXYCYCLINE, 100 MG DAILY, 2 DAYS BEFORE
ENTERING THE ENDEMIC AREA, WHILE THERE, AND FOR 4
WEEKS AFTER LEAVING (THIS DRUG AVAILABLE IN INDONESIA).(THIS DRUG AVAILABLE IN INDONESIA). - 2. MALARONE (ATOVAQUONE 250 MG + PROGUANIL 100
MG), ONE TABLET DAILY, ONE TABLET THE DAY BEFORE
ENTERING THE ENDEMIC AREA, WHILE THERE, AND FOR 1
WEEK AFTER LEAVING
CHEMOPROPHYLAXIX (5)- OTHER ALTERNATIVES:
DAILY PROGUANIL 200 MG + WEEKLY CHLOROQUINE
0.5 G, MORE PROTECTION THAN CHLOROQUINE
ALONE
CHEMOPROPHYLAXIX (6)c. PROPHYLAXIS FOR PREGNANT WOMEN
- THE BEST COURSE IS WEEKLY CHLOROQUINE +/– PROGUANIL - IN AREAS OF CHLOROQUINE-RESISTANT MALARIA
MEFLOQUININE, EXCEPT IN THE FIRST TRIMESTER
- DRUGS CONTRAINDICATED ARE DOXYCYCLINE &
PRIMAQUINE
PENGOBATAN MALARIAPENGOBATAN MALARIA
Golongan Jenis obatCinchona alkaloids Quinine4-aminoquinolines Chloroquine, amodiaquine
8-aminoquinolines Primaquine, tafenoquine, Pamaquine
4-quinoline methanols Mefloquine
9-phenanthrene methanols Halofantrine
Antifolic drugs Pyrimethamine, proguanil
Sulfa drugs a) sulphones; dapsone b) sulphonamides; sulphadoxine
Sesquiterpene lactones (Artemisinin derivatives)
a) artemisinin, dihydroartemisinin b) artesunate, artemether, arteether
Antibiotics Tetracycline, doksisiklin, chloramphenicol, Fluoroquinolon, azithromycin, clindamycin, rifampicin,
Combination 1. Artemether-lumefantrine (Coartem) ***2. Artesunate + amodiaquine3. Artesunate + mefloquine4. Artesunate + sulfadoxine-pyrimethamine ('Fansidar')
Riwayat resistensi obat Riwayat resistensi obat antimalariaantimalaria
ObatDiperkenalkan
Laporan pertama
resistensi
Beda waktu(tahun)
Quinine 1632 1910 278
Chloroquine 1945 1957 12
Mefloquine 1977 1982 5
Proguanil 1948 1949 1
Artemisinin 2000 2001 <1<1
Sulphadoxi-pyrimethamine (Fansidar)
1967 1967 0
Atovaquone 1996 1996 0
ACT ( Artemisinin Combination ACT ( Artemisinin Combination Treatment ) Treatment )
Artesunate + mefloquineArtesunate + mefloquine Artesunate + Sulphadoxine-PirimethamineArtesunate + Sulphadoxine-Pirimethamine Artesunate + PyronaridineArtesunate + Pyronaridine Artesunate-NaphthoquineArtesunate-Naphthoquine Artesunate + amodiaquine: Arsuamoon, ArtesdiaquineArtesunate + amodiaquine: Arsuamoon, Artesdiaquine Artemeter + lumefantrine ( COARTEM )Artemeter + lumefantrine ( COARTEM ) Dihydroartemisinin-Piperaquine(DHP), Arterekin, ArtepDihydroartemisinin-Piperaquine(DHP), Arterekin, Artep Dihydroartemisinin-Piperaquine-Trimetoprim (DPT)Dihydroartemisinin-Piperaquine-Trimetoprim (DPT) Dihydroartemisinin-Piperaquine-Trimetoprim, primaquine Dihydroartemisinin-Piperaquine-Trimetoprim, primaquine
(CV8)(CV8)
Kina HCl
•Obat anti malaria yang sangat efektif untuk semua jenis plasmodium •Efektif sebagai skizontosida maupun gametosida •Masih berefek kuat terhadap P. falcifarum yang resisten terhadap klorokuin.•Dapat diberikan dengan cepat dengan intra vena & cukup aman
Pemberian Pemberian Kina HCl Kina HCl Cara pemberian & dosis: Cara pemberian & dosis: Dosis loading 20 mg /kgBB Kina HCl dalam 100-200 Dosis loading 20 mg /kgBB Kina HCl dalam 100-200
cc cairan dekstrose 5% atau NaCl 0,9% selama 4 jam, cc cairan dekstrose 5% atau NaCl 0,9% selama 4 jam, - dilanjutkan dengan - dilanjutkan dengan 10 mg /KgBB dilarutkan dalam 10 mg /KgBB dilarutkan dalam
200 cc dekstrose 5% diberikan dalam waktu 4 jam 200 cc dekstrose 5% diberikan dalam waktu 4 jam -selanjutnya diberikan -selanjutnya diberikan dosis yang sama setiap 8 jam dosis yang sama setiap 8 jam --Apabila penderita sudah sadar, kina R/ peroral dgn Apabila penderita sudah sadar, kina R/ peroral dgn
dosis 3 x 300-600 mg selama 7 hari dihitung dari hari dosis 3 x 300-600 mg selama 7 hari dihitung dari hari I dosis parenteral.I dosis parenteral.
Dosis
i.v.i.v. 2,4 mg/kg BB pada jam 0, dan jam 12, 2,4 mg/kg BB pada jam 0, dan jam 12, kemudian dilanjutkan jam 24, 48 dst sampai 7 kemudian dilanjutkan jam 24, 48 dst sampai 7 hari. Dosis total 17 – 18 mg/ 7 hari ( 1 Amp= hari. Dosis total 17 – 18 mg/ 7 hari ( 1 Amp= 60 mg) atau 60 mg) atau
IVIV: 2,4/kgBB: 2,4/kgBB1,2 1,2 1,2 1,2 , 1,2 , 1,2 ,1,2/kgBB/24 jam ,1,2/kgBB/24 jam
3.23.2 mg/kg mg/kg IMIM pada hari I dibagi 2 dosis, pada hari I dibagi 2 dosis, dilanjutkan 1.6 mg/kg/ hari. dilanjutkan 1.6 mg/kg/ hari. TIDAK ivTIDAK iv (1 amp = (1 amp = 80 mg)80 mg)
SuppositoriesSuppositories, 1, 10 mg/kg at 0 & 4 hr followed by 0 mg/kg at 0 & 4 hr followed by 7 mg/kg at 24,36,48 & 60 hrs.7 mg/kg at 24,36,48 & 60 hrs.
ARTEMETER
DRUGS SIDE EFFECTS
ARTEMISININ
ARTESUNATE
Neurotoxicity in animal not human
WHO 2006 : AS is the recommended FIRST CHOICE in area low transmission
RECOMMENDED DOSES OF ANTI MALARIAL RECOMMENDED DOSES OF ANTI MALARIAL DRUGS FOR TREATMENT OF SEVERE MALARIADRUGS FOR TREATMENT OF SEVERE MALARIA
DRUGS DosisARTESUNATE
IV 2,4 mg/kg BB pada jam 0, dan jam 12, kemudian dilanjutkan jam 24, 48 dst sampai 7 hari. Dosis total 17 – 18 mg/ 7 hari ( 1 Amp= 60 mg)
atau IV: 2,4/kgBB1,2 1,2 , 1,2
,1,2/ kgBB/ 24 jam ARTEMETER 3.2 mg/kg IM pada hari I dibagi 2
dosis, dilanjutkan 1.6 mg/kg/ hari. TIDAK IV (1 amp = 80 mg)
ARTEMISININ Suppositories, 10 mg/kg at 0 & 4 hr followed by 7 mg/kg at 24,36,48 & 60 hrs.
Neurotoxaicity in animal not human
DOSIS ARTEMISININ PADA MALARIA BERATDOSIS ARTEMISININ PADA MALARIA BERAT
0 JAM 12.J 24.J 48.J 72.J Max 7 hari
2.4 Mg/KgBB
2.4 Mg/KgBB
2.4 Mg/KgBB
2.4 Mg/KgBB
2.4 Mg/KgBB
ARTESUNATE I.V/ I.M
* ARTEMETER , hanya I.M , dosis 1,6 mg/kg BB
ARTESUNATEI.V / I.M
1 Fl = 60 mg
ARTEMETHER I.M1 Amp = 80mg
Arthemeter-Lumefantrine vs Arthemeter-Lumefantrine vs Artesunate + AmodiaquineArtesunate + Amodiaquine
295 children > 5 years, Burundi, 14 295 children > 5 years, Burundi, 14 days :days :– ACPR : 99.3% (140/141), 95% CI:97.9-ACPR : 99.3% (140/141), 95% CI:97.9-
100% with AL vs 95.3% (142/149); 95% 100% with AL vs 95.3% (142/149); 95% CI: 91.9-98.7% with AS + AmoCI: 91.9-98.7% with AS + Amo
– Adverse events : vomiting on D1 1.5% Adverse events : vomiting on D1 1.5% AL vs 13% AS+Amo; on D2 : 1%AL vs AL vs 13% AS+Amo; on D2 : 1%AL vs 5% AS+Amo5% AS+Amo
Pengobatan malariaPengobatan malaria– Pengobatan malaria tanpa komplikasiPengobatan malaria tanpa komplikasi
Malaria Malaria falsiparumfalsiparum– Lini pertama:Lini pertama:– Artesunat+Amodiaquin+PrimakuinArtesunat+Amodiaquin+Primakuin
Dosis: diberikan selama tiga hariDosis: diberikan selama tiga hari Hari I:Hari I:
– Artesunat: 4 tablet + Amodiakuin 4 tablet + Artesunat: 4 tablet + Amodiakuin 4 tablet + Primakin 3 tabletPrimakin 3 tablet
Hari II:Hari II:– Artesunat: 4 tablet + Amodiakuin 4 tabletArtesunat: 4 tablet + Amodiakuin 4 tablet
Hari III:Hari III:– Artesunat: 4 tablet + Amodiakuin 4 tabletArtesunat: 4 tablet + Amodiakuin 4 tablet
Pengobatan malaria tanpa komplikasiPengobatan malaria tanpa komplikasiP. falciparumP. falciparum
Lini pertama:Lini pertama: Artesunat+Amodiaquin+PrimakuinArtesunat+Amodiaquin+Primakuin
HARI I Artesunat: 4 tablet + Amodiakuin 4 tablet + Primakin 3 tablet
HARI 2 4 tablet + Amodiakuin 4 tablet
HARI 3 4 tablet + Amodiakuin 4 tablet
Terapi malaria lini pertamaTerapi malaria lini pertamaHari Jeniss obat ≥ 15tahun/Tab
I Artesunat 4Amodiakuin 4Primakuin 2-3
2 Artesunat 4Amodiaquin 4
3 Artesunat 4Amodiakuin 4
SECOND LINE: severe malariaSECOND LINE: severe malariaLokasi Drugs/Dosis
Hospitalized patient
Quinine HCl 25 % in NaCl 0,9 % or Dextrosa 5 % per infusion, Dosage: 10 mg/KbBW/4 hour every 8 hours.Total dosage Quinine 30 mg/KgBW/24 hours
Patient in the field
Quinine HCl 25 % in NaCl 0,9 % or Dextrose 5 % intra muscular/IM: Dosage:10 mg/KbBW/4 hour every 8 hours.Total dosage qunine 30 mg/Kg BW/24 hours
If able to drink
follows by Quinine tab. + Doxy/ tetra capsule 7 days.
Pengobatan Pengobatan lini kedualini kedua bila terjadi bila terjadi rekrudensis atau justeru parasit rekrudensis atau justeru parasit
menetap (persisten)menetap (persisten)
Kina + doksisiklin Kina + doksisiklin 7 hari7 hari
atau atau
Tetrasiklin + primakuinTetrasiklin + primakuin
Derivat tetrasiklin
• Obat antibiotik yang bersifat sebagai anti malaria • Bersifat sebagai skizontosida jaringan P. falcifarum dan skizontosida darah untuk semua jenis plasmodium manusia
PrimakuinPelengkap pengobatan radikal P. falciparum u/ mencegah terjadinya penularan
PROGNOSISPROGNOSIS
UNCOMPLICATED & WITH PROMPT ANTIMALARIAL THERAPY GOOD
P. FALCIPARUM INFECTIONS WITH SEVERE COMPLICATIONS POOR
MORTALITYMORTALITY 0.1% case fatality rate provided 0.1% case fatality rate provided
prompt and effective treatmentprompt and effective treatment Ineffective, delayed Ineffective, delayed severe severe
malariamalaria Severe malaria, mortality Severe malaria, mortality 15 – 20 %15 – 20 % Untreated severe malaria, almost Untreated severe malaria, almost
always always fatalfatal / infaust / infaust
DOSIS
RECOMMENDED DOSES OF ANTI MALARIAL DRUGS RECOMMENDED DOSES OF ANTI MALARIAL DRUGS FOR TREATMENT OF SEVERE/CEREBRAL MALARIA FOR TREATMENT OF SEVERE/CEREBRAL MALARIA
XXXXXX
Hypoglycemia, Hypoglycemia, chinchonism, chinchonism, tinnitus, hearing tinnitus, hearing impairment, nausea, impairment, nausea, dysphoria, vomiting, dysphoria, vomiting, prolonged QT prolonged QT interval, interval, dysrhythmias, dysrhythmias, hypotensionhypotension
20 mg of dihydrochloride salt/kg by iv 20 mg of dihydrochloride salt/kg by iv infusion over 4 hr, then after infusion over 4 hr, then after loading, followed by 10 mg/kg over loading, followed by 10 mg/kg over 4 hr every 8 hr. Patients should not 4 hr every 8 hr. Patients should not received quinine or mefloquine received quinine or mefloquine within last 24 hrwithin last 24 hr
Alternatively, 7 mg of salt/kg can be Alternatively, 7 mg of salt/kg can be infused over a period of 30 min, infused over a period of 30 min, followed by 10 mg salt/kg over a followed by 10 mg salt/kg over a period of 4 hr, orperiod of 4 hr, or
10 mg of salt/kg (500 mg for adult) by 10 mg of salt/kg (500 mg for adult) by i.v infusion over 8 hr continously 3 i.v infusion over 8 hr continously 3 x a dayx a day
QuinineQuinine
DRUGSDRUGS SIDE EFFECTSSIDE EFFECTS
Pengobatan Pengobatan lanjutanlanjutan
Setelah pasien sadar/KU membaik, tx. Awal Setelah pasien sadar/KU membaik, tx. Awal parenteral dapat diubah dgn. Tx. Oralparenteral dapat diubah dgn. Tx. Oral
Diteruskan dengan :Diteruskan dengan : ACT dosis lengkap (selama 3 hari): AL , AS + AQACT dosis lengkap (selama 3 hari): AL , AS + AQ Artesunate/artemether tab. (total 7 hari ) + Artesunate/artemether tab. (total 7 hari ) +
doksisiklin 3-5 Kg BB 1 kali sehari selama 7 haridoksisiklin 3-5 Kg BB 1 kali sehari selama 7 hari Kina tab.(total 7 hari) + doksisiklin 7 hariKina tab.(total 7 hari) + doksisiklin 7 hari Bagi Bagi bumilbumil, anak-anak : doksisiklin diganti , anak-anak : doksisiklin diganti
dengan dengan klindamisin 10klindamisin 10 mg/Kg BB 2 kali sehari mg/Kg BB 2 kali sehari
Artemisinin-base Combination Artemisinin-base Combination Therapy (A.C.T)Therapy (A.C.T)
Rapid clerance parasitesRapid clerance parasites Rapid resolution of symptomsRapid resolution of symptoms Reduce parasites rapidlyReduce parasites rapidly
Recommendation WHO 2006 Recommendation WHO 2006 in using ACTs :in using ACTs :
Artemether-lumefantrineArtemether-lumefantrine Artesunate + amodiaquineArtesunate + amodiaquine Artesunate + mefloquineArtesunate + mefloquine Artesunate + sulfadoxine-Artesunate + sulfadoxine-
pyrimethamine/Fanidarpyrimethamine/Fanidar
ARTEMISININ FOR ARTEMISININ FOR SEVERE MALARIASEVERE MALARIA
Artesunate/ ARTS ( i.v./ i.m / Artesunate/ ARTS ( i.v./ i.m / supp)supp)
Artemether / ARTM (i.m.)Artemether / ARTM (i.m.) Arte-ether (i.m )Arte-ether (i.m ) Artemisinin ( supp )Artemisinin ( supp ) Dihydro-artemisinin ( supp )Dihydro-artemisinin ( supp ) Artelinate ( i.v)Artelinate ( i.v)
ANTI-BIOTICANTI-BIOTIC
DoxycyclinDoxycyclin TetrascyclineTetrascycline ClindamycinClindamycin AzithromycinAzithromycin
NEW ANTI MALARIA DRUGS - 2NEW ANTI MALARIA DRUGS - 2 ATOVAQUONEATOVAQUONE YINGHAOSUYINGHAOSU PIRONARIDINPIRONARIDIN ETAKUIN/ PIPERAKUINETAKUIN/ PIPERAKUIN BENFLUMETOL ( Lumefantrine )BENFLUMETOL ( Lumefantrine ) MEFLOQUINEMEFLOQUINE TAFENOQUINETAFENOQUINE SAMBILOTOSAMBILOTO
PENGOBATANPENGOBATAN
2. 2. Terapi SupresifTerapi Supresif Meringankan gejala Meringankan gejala KlorokinKlorokin
– Pendatang sementara ke daerah endermisPendatang sementara ke daerah endermis Klorokin : Klorokin : 300 Mg/Mgg300 Mg/Mgg 1 Mg 1 Mg selama di lokasi selama di lokasi 4 Mg 4 Mg
– Penduduk setempat dan penduduk baru yang Penduduk setempat dan penduduk baru yang akan menetapakan menetap Klorokin sekali/Mg Klorokin sekali/Mg 6 tahun atau 6 tahun atau Amodiakin 600 mg/2 mingguAmodiakin 600 mg/2 minggu
– Semua penderita demam di daerah endemis Semua penderita demam di daerah endemis Klorokin 600 mg, bila resistens Klorokin 600 mg, bila resistens Primakin 3 Primakin 3
tabtab Primakuin 1x1Primakuin 1x1
PENGOBATANPENGOBATAN Mepakrin 100 mg/hariMepakrin 100 mg/hari
– 2 Mg 2 Mg selama di lokasi selama di lokasi 4 mg 4 mg Pirimetamin (daraprim) 50 mingguPirimetamin (daraprim) 50 minggu
– 1 Mg 1 Mg selama di lokasi selama di lokasi 4 mg 4 mg Proguanil 100 mg/hr atau 300 mg/mingguProguanil 100 mg/hr atau 300 mg/minggu
– 1 Mg 1 Mg selama di lokasi selama di lokasi 4 Mg 4 Mg Kina satu tablet (250 mg)/hrKina satu tablet (250 mg)/hr
– 1 Mg 1 Mg selama di lokasi selama di lokasi 4 Mg 4 Mg Fansidar/suldox 1 tablet/mingguFansidar/suldox 1 tablet/minggu Doxycycline, 100 mg daily, 2 days before entering
the endemic area, while there, and for 4 weeks after leaving (this drug available in indonesia).(this drug available in indonesia).
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