Artemisin Combined Therapy in malaria patients: Do we need to search for more?

Chinmay Jani, Neil Palkhiwala, Ami Parikh, Nilay Suthar, Khushali Patel,


Introduction: Malaria is a vector borne disease highly prevalent in the topical developing countries. Two main species of plasmodium causing majority of diseases manifestations are P. Vivax and P. falciparum. The approach to antimalarial selection is determined based on the location of the patient. For treatment of uncomplicated P. falciparum malaria, according to WHO guidelines first line therapy mainly includes Artemisin Combined Therapy. Concerns about the emergence of resistance to artemisin derivatives have increased recently. The main aim of the present study is to investigate the effect of using a combination of intravenous artesunate along with oral doxycycline, as a novel ACT for Malarial infections – falciparum vs. vivax. Methodology: Prospective observational study was carried out at V S General Hospital in Ahmedabad, Gujarat, India. A full history of current illness was taken followed by examining the serial peripheral smear reports of the patients till the malarial parasites are not seen on two consecutive occasions. Samples were taken at least 6 hours apart by the capillary method and oral temperature was measured every 6 hours. We excluded other associated viral fevers such as dengue, pediatric age group (<12 years) and Co-Morbid illnesses like hepatic or renal dysfunction. Data analysis was done using SPSS software version 20. Results: Student t test showed that PCT was significantly more in falciparum (mean= 74.53 hours) patients as compared to vivax patients (mean= 51.89 hours). (p<0.001). Also duration of stay was significantly more in patients having falciparum (mean =3.63 days) as compared to patients having vivax (mean = 2.32 days) (p<0.001) Multivariate analysis by linear regression showed that species of the parasite was the most significant independent predictor (B=12.552) of the time to parasite clearance and other significant variable was Grade of parasitemia at 0 hour (B= 12.798). We also found that patients with residual parasitemia was 83.78%, 40.54% and 10.81% in vivax group whereas it was 100%, 88.15% and 46.05% in falciparum respectively at 24, 48 and 72 hours. Conclusion: The study shows that PCT and residual parasitemia is very high in falciparum patients as compared to previous reports of different studies and also as compared to vivax group patients. ACT resistance is a grave concern for falciparum and more studies should be done to understand pathophysiology and its prevalence in India. We strongly suggest that a continues monitoring needs to be implemented in health policy to understand the dynamicity of emerging resistance

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Deribew A, Dejene T, Kebede B, et al. Incidence, prevalence and mortality rates of malaria in Ethiopia from 1990 to 2015: analysis of the global burden of diseases 2015. Malar J. 2017 Jul 4;16(1):271. doi: 10. 1186/s12936-017-1919-4.

Bagcchi S. Progress on malaria stalls amid decline in funding. BMJ. 2017 Dec 5;359:j5645. doi: 10.1136/ bmj.j5645.

Lufele E, Umbers A, Ordi J, Ome-Kaius M, Wangnapi R, Unger H, et al. Risk factors and pregnancy outcomes associated with placental malaria in a prospective cohort of Papua New Guinean women. Malaria journal. 2017;16(1):427.

Guidelines for the treatment of malaria, 3rd ed, WHO.

Newton P, White N. Malaria: new developments in treatment and prevention. Annu Rev Med. 1999;50:179-92. doi:10.1146/

Douglas NM, Anstey NM, Angus BJ, et al. Artemisinin combination therapy for vivax malaria. Lancet Infect Dis. 2010 Jun;10(6):405-16. doi: 10.1016/ S1473-3099(10)70079-7.

Douglas NM, Nosten F, Ashley EA, et al. Plasmodium vivax recurrence following falciparum and mixed species malaria: risk factors and effect of antimalarial kinetics. Clin Infect Dis. 2011 Mar 1;52(5): 612-20. doi: 10.1093/cid/ciq249.

Ashley EA, Dhorda M, Fairhurst RM, Spread of artemisinin resistance in Plasmodium falciparum malaria. N Engl J Med. 2014 Jul 31;371(5):411-23. doi: 10. 1056/NEJMoa1314981.

Dondorp AM, Nosten F, Yi P, Artemisinin resistance in Plasmodium falciparum malaria. N Engl J Med. 2009 Jul 30; 361 (5): 455-67. doi: 10.1056/ NEJM oa0808859.

Price RN, Douglas NM, Anstey NM, von Seidlein L. Plasmodium vivax treatments: what are we looking for? Curr Opin Infect Dis. 2011 Dec;24(6):578-85. doi: 10.1097/QCO.0b013e32834c61e3.

Chan WW, Virmani D, Pillai DR. Artemisinin combination therapy can result in clinical failure if oral therapy is not directly observed. The Canadian journal of infectious diseases & medical microbiology = Journal canadien des maladies infectieuses et de la microbiologie medicale. 2013;24(4):215-6.

Thita T, Jadsri P, Thamkhantho J, Phenotypic and genotypic characterization of Thai isolates of Plasmodium falciparum after an artemisinin resistance containment project. Malar J. 2018 May 15;17(1):197. doi: 10.1186/s12936-018-2347-9.

Singh GP , Goel P, Sharma A. Structural mapping of Kelch13 mutations associated with artemisinin resistance in malaria. J Struct Funct Genomics. 2016 Sep;17(2-3):51-6. doi: 10.1007/s10969-016-9205-1. Epub 2016 Jul 11.

Salam N, Mustafa S, Hafiz A, et al. Global prevalence and distribution of coinfection of malaria, dengue and chikungunya: a systematic review. BMC Public Health. 2018 Jun 8;18(1):710. doi: 10.1186/ s12889-018-5626-z.

Sehgal PN. Malaria: radical treatment for falciparum malaria in chloroquine resistant strain areas. Health Millions. 1998 Nov-Dec;24(6):18-9.

Dash AP, Valecha N, Anvikar AR, Kumar A. Malaria in India: challenges and opportunities. J Biosci. 2008 Nov;33(4):583-92.

Sinha S, Medhi B, Sehgal R. Challenges of drug-resistant malaria. Parasite. 2014; 21:61. doi: 10.1051/ parasite/2014059. Epub 2014 Nov 18.

Parija SC , Praharaj I. Drug resistance in malaria. Indian J Med Microbiol. 2011 Jul-Sep;29(3):243-8. doi: 10.4103/0255-0857.83906.

Bharti PK, Shukla MM, Ringwald P, Krishna S, Singh PP, Yadav A, et al. Therapeutic efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria from three highly malarious states in India. Malaria journal. 2016;15(1):498.

Borrmann S, Sasi P, Mwai L, Bashraheil M, Abdallah A, Muriithi S, et al. Declining responsiveness of Plasmodium falciparum infections to artemisinin-based combination treatments on the Kenyan coast. PloS one. 2011;6(11):e26005.


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