Evidence Based Presentation (Drug Resistance in Malaria)

Evidence Based Presentation (Drug Resistance in Malaria)


            Malaria is a very serious disease that has led to a number of mortality cases in areas where it is common. It is, therefore, a very vital public health concern in both the places where occurrence of the transmission is regular and where transmissions have been controlled. This is basically attributed to the fact that malaria is caused by different species of the parasite. Because of this, there is a great variation in epidemiology and manifestation of the disease as one moves from one region to another. There is a great variation when it comes to the susceptibility of the parasite species that cause malaria to anti-malarial drugs (World Health Organization, 2000).  A factor that also contributes to this is the level and behavior of acquired immunity of populations that are exposed to malaria. The individuals who are always at greater risk of succumbing to malaria are pregnant women, children, and even visitors in areas where malaria is common. The greatest clinical practice problem that has resulted in the treatment of malaria is the resistance of different species of the parasites that cause malaria to anti-malarial drugs. For instance, it has been noted that P. flaciparum is not sensitive to Chloroquiene (CQ) in areas such as South America and Africa while it is used as a first line drug for the treatment of P. flaciparum caused malaria which is not severe in areas such as Haiti and Dominica Republic.

            The resistance to anti-malarial drugs by the parasite species that cause malaria has resulted to a widespread of the disease in areas that had no cases of malaria and reemergence cases in other parts. Because of this, there has been an increase in the epidemic occurrence and severity in a number of parts of the world. This has been advanced further by the movement of population. It has been noted that there is some level of resistance to almost all the anti- malarial drugs that are available. Nurses should, therefore, have the knowledge of this practice problem so that they can correctly apply the evidence based practice from the scientific research in the improvement of the healthcare services. The standard clinical guideline in focus in this paper uses Dihydroartemisinin-piperaquine (DP) which, according to research work carried in Cambodia, has demonstrated high levels of efficacy in the treatment of P. falciparum caused malaria (World Health Organization, 2000). In other cases, combination therapy with anti-malarial drugs has been used as a standard guideline for solving the problem associated with the resistance to anti-malarial drugs by different species of the parasite. Most of the anti-malarial drugs that have been found to be effective in combination therapy are those with different mechanism of action. This makes it impossible for the development of resistance by parasite species on both compounds in the drugs. For example, it has been shown that there is some level of efficacy when 4-aminoquinoline drug is combined with sulfadoxine in addition to amodia quine. This has resulted to enhanced clearance of the parasites (Myint et al., 2007). However, there is a need to establish the reaction of this kind of combination in areas which have shown some level of resistance to either of the compounds in the drugs used in combination therapy.

The guideline in focus was developed by Rithea Leang, Amy Barrette, Denis Mey Bouth, Didier Menard , Rashid Abdur, Socheat Duong and Pascal Ringwald who are very qualified medical professionals. They also used very authentic standard guidelines from World Health Organization in their research and studies in general. In their work, each and every single patient gave his/her medical history during enrolment (Myint et al., 2007). Biological, clinical, and physical examination were also done and the axillary temperature measured on a daily basis. Blood samples for thin and thick film tests were taken for the purposes of determining the count of the asexual parasites and the species of the parasites. In this study, after the clearance of the parasites and establishment of their absence for two days, the patients were made to return once in a week for a period of 28 days for those who had P. vivax, and a period of 42 days for patients who had P. falciparum. Consistent home visits were also made in the case of patients who had P. falciparum in instances where they failed to come for the appointments. The establishment of the sample size in this study was in line with the recommendations of World Health Organization (WHO) and all the ethical issues of research were adhered to since the study was done under the approval of National Ethics Committee (National Institute of Public Health). With the ANZCTTR registration numbers of 12612000184875, 12612000183886, and 12612000181808, the study qualify to be authentic and can be relied on (Myint et al., 2007). The work also made sure that the regime of treatment was tailored to the region under study (Cambodia) in relationship to the pattern of resistance in the area. It can also be noted that the study factored in the aspects of cost-effectiveness, administration ease, and availability.

The choice of Dihydroartemisinin-piperaquine (DP) was based on the fact that it had shown some high levels of efficacy not only in Cambodia, but also in parts of Southeast Asia where the approach had been employed (World Health Organization, 2009). What makes this approach to have advantage over other approaches is its co-formulation. In the Cambodian-Thailand project, DP was used majorly to contain the resistance to artemisinin. Because of high failure of chloroquine (CQ) with regards to treatment of P. vivax in Cambodia, DP has been adopted as the first line treatment of cases of P. vivax infections. In a more general sense, World Health Organization has recommended artemisinin combination therapy (ACT) for the treatment of P. vivax (World Health Organization, 2010).

Body of evidence table

Research Study CitationBrief summary of the Study and resultsLevel of Evidence
Phyo et al., 2011The study focused on the comparison of effectiveness of Dihydroartemisinin-piperaquine in the treatment of Plasmodium vivax malaria in Thailand and chloroquine. From the study, DP showed high efficacy.Level two.
Karunajeewa et al., 2008The study focused on the trial of combination anti-malarial therapies in children from Papua New Guinea. From the study, it was established that DP showed efficacy in the treatment of P. falciparum.Level two.
Jansen et al., 2007The study focused on the assessment of the efficacy and tolerability of dihydroartemisinin piperaquine for the treatment of uncomplicated falciparum malaria in Cambodia. The result of the study also confirmed the efficacy of DP in the treat of P. falciparum.Level two.
Myint et al.,This study focused on the efficacy and safety of dihydroartemisinin piperaquine and it established that DP was effective.Level two.
Denis et al.,The study focused on the surveillance of the efficacy of artesunate and mefloquine combination for the treatment of uncomplicated falciparum malaria in Cambodia. According to the study, there was low efficacy artesunate and mefloquine combination for the treatment of uncomplicated falciparum malaria.Level three

            The changes suggested here should be effected by all medical professional and more so, pharmacists and nurses. This change in the treatment of P. falciparum and P.vivax would contribute immensely in controlling malaria and it should be done immediately to reduce mortality case as a result of drug resistance (Phyo et al., 2011).

The outcome

            In this study, the outcomes of treatment were categorized in line with the assessment of parasitogical and clinical outcomes. This was in compliance with the methods recommended by World Health Organization (Karunajeewa et al., 2008). According to this study which involved 438 patients who were infected by P. falciparum, it was noted that 5 patients were censored before the third day while 22 were censored from the analysis on the forty second day. In general, it was established that the efficacy of therapy of DP had some significant increase in the number of patients who showed positive reaction on the third day. Thus, for the treatment of P. falciparum with DP in areas in Cambodia such as Preah Vihear and Ratanakiri provinces in northern and eastern Cambodia, there was 100% effectiveness and with regards to P. vivax, there was 100% effectiveness in all the areas that were involved in the study (Myint et al., 2007).


            Drug resistance remains a major clinical challenge in the treatment of malaria worldwide. More research should be done to come up with a better way of solving this problem. It is also important for nurses to use the findings from scientific research in their daily evidence practice for the purpose of improving healthcare.


Karunajeewa, H. A., Mueller, I., Senn, M., Lin, E., Law, I., Gomorrai, P. S., Oa, O., Griffin, S., Kotab, K., Suano, P., Tarongka, N., Ura, A., Lautu, D., Page-Sharp, M., Wong, R., Salman, S., Siba, P., Ilett, K. F., & Davis, T. M. (2008).A trial of combination antimalarial therapies in children from Papua New Guinea. N. Engl. J. Med. 24: 2545–2557.

Myint H.Y., Ashley, E. A., Day, N. P., Nosten, F., White, N. J. (2007). Efficacy and safety of dihydroartemisinin-piperaquine. Trans. R. Soc. Trop. Med. Hyg. 101: 858–866.

Myint, H. Y., Ashley, E. A., Day, N. P., Nosten, F., & White, N. J. (2007). Efficacy and safety of dihydroartemisinin-piperaquine. Trans. R. Soc. Trop. Med. Hyg. 101: 858–866.

Phyo, A. P., Lwin, K. M., Price, R. N., Ashley, E. A., Russell, B., Sriprawat, K., Lindegardh, N., Singhasivanon, P., White, N. J., & Nosten, F. (2011). Dihydroartemisinin-piperaquine versus chloroquine in the treatment of Plasmodium vivax malaria in Thailand: a randomized controlled trial. Clin. Infect. Dis. 53: 977–984.

World Health Organization. (2000). Global malaria control and elimination: report of a meeting on containment of artemisinin tolerance. World Health Organization, Geneva, Switzerland.

World Health Organization. (2009). Methods for surveillance of antimalarial drug efficacy. World Health Organization, Geneva, Switzerland.

World Health Organization. (2010). Treatment guidelines for malaria (2nd ed.). World Health Organization, Geneva, Switzerland

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