疟疾诊疗指南

doi:10.12140/j.issn.1000-7423.2022.04.001

摘要/Abstract

摘要：

疟疾是疟原虫感染所致的地方性传染病,主要在热带和亚热带地区流行。尽管世界卫生组织在2021年6月宣布我国通过了消除疟疾认证,但随着国际交流的日益频繁,我国面临的输入性疟疾的威胁将长期存在。为促进临床医师深入了解并合理治疗疟疾,提高疟疾诊治的水平,我们邀请国内感染性疾病及寄生虫病领域相关专家共同编写了“疟疾诊疗指南”（简称“指南”）。该指南对疟疾的病原学、流行病学、发病机制、临床表现、实验室检查、诊断及鉴别诊断、治疗、护理、预防等方面进行介绍,并重点强调了应对不同临床状况时的治疗方案,以便临床医师合理应用。

关键词: 疟疾, 诊断, 治疗, 指南

Abstract:

Malaria is an endemic infectious disease caused by Plasmodium and is mainly prevalent in tropical and subtropical areas. Despite the World Health Organization’s announcement of the country’s malaria elimination certification in 2021, the threat of imported malaria will persist as international travel increases. In order to facilitate clinicians’ understanding and rational treatment of malaria and to improve the diagnosis and treatment of malaria, we have invited experts in the relevant field of infectious diseases and parasitic diseases in China to prepare the guidelines for malaria diagnosis and treatment. The guidelines introduce the etiology, epidemiology, pathogenesis, clinical manifestations, diagnosis and differential diagnosis, treatment, care, and prevention of malaria, emphasising on treatment options for different clinical conditions, so that the clinician can use them properly.

Key words: Malaria, Diagnosis, Treatment, Guidelines

中图分类号:

R531.3

国家传染病医学中心撰写组. 疟疾诊疗指南[J]. 中国寄生虫学与寄生虫病杂志, 2022, 40(4): 419-427.

Expert Group of National Center for Infectious Diseases. Guidelines for malaria diagnosis and treatment[J]. Chinese Journal of Parasitology and Parasitic Diseases, 2022, 40(4): 419-427.

图/表 1

表1

基于青蒿素的联合疗法（WHO推荐剂量）

药物名称	剂型	体质量/kg	用法用量
蒿甲醚/苯芴醇	片剂,复方制剂,由蒿甲醚和苯芴醇组成,每片蒿甲醚40 mg + 苯芴醇240 mg		口服,2次/d,共3 d
		5~< 15	蒿甲醚20 mg + 苯芴醇120 mg
		15~< 25	蒿甲醚40 mg + 苯芴醇240 mg
		25~< 35	蒿甲醚60 mg + 苯芴醇360 mg
		≥ 35	蒿甲醚80 mg + 苯芴醇480 mg
青蒿琥酯/阿莫地喹	片剂,复方制剂,由青蒿琥酯和阿莫地喹组成国内剂型：每片青蒿琥酯100 mg+阿莫地喹270 mg 国外剂型还包括：每片青蒿琥酯25 mg + 阿莫地喹67.5 mg 每片青蒿琥酯50 mg + 阿莫地喹135 mg		口服,2次/d,共3 d
		4.5~< 9	青蒿琥酯25 mg + 阿莫地喹67.5 mg
		9~< 18	青蒿琥酯50 mg + 阿莫地喹135 mg
		18~< 36	青蒿琥酯100 mg + 阿莫地喹270 mg
		≥ 36	青蒿琥酯200 mg + 阿莫地喹540 mg
双氢青蒿素/磷酸哌喹	片剂,复方制剂,由双氢青蒿素和磷酸哌喹组成国内剂型：每片双氢青蒿素40 mg + 磷酸哌喹320 mg 国外剂型还包括：每片双氢青蒿素20 mg + 磷酸哌喹160 mg		口服,2次/d,共3 d
		5~< 8	双氢青蒿素20 mg + 磷酸哌喹160 mg
		8~< 11	双氢青蒿素30 mg + 磷酸哌喹240 mg
		11~< 17	双氢青蒿素40 mg + 磷酸哌喹320 mg
		17~< 25	双氢青蒿素60 mg + 磷酸哌喹480 mg
		25~< 36	双氢青蒿素80 mg + 磷酸哌喹640 mg
		36~< 60	双氢青蒿素120 mg + 磷酸哌喹960 mg
		60~< 80	双氢青蒿素160 mg + 磷酸哌喹1 280 mg
		≥ 80	双氢青蒿素200 mg + 磷酸哌喹1 600 mg
青蒿琥酯-甲氟喹	片剂,联合用药,由青蒿琥酯片和甲氟喹片组合包装国内无生产厂家国外剂型包括：每片青蒿琥酯25 mg + 甲氟喹55 mg 每片青蒿琥酯100 mg + 甲氟喹220 mg		口服,1次/d,共服3 d
		5~< 9	青蒿琥酯25 mg + 甲氟喹55 mg
		9~< 18	青蒿琥酯50 mg + 甲氟喹110 mg
		18~< 36	青蒿琥酯100 mg + 甲氟喹220 mg
		≥ 36	青蒿琥酯200 mg + 甲氟喹440 mg
青蒿琥酯-磺胺多辛-乙胺嘧啶	联合用药,由青蒿琥酯片和磺胺多辛-乙胺嘧啶（SP）片组合包装由25 mg/片的青蒿琥酯片和500 mg/片磺胺多辛 + 25 mg乙胺嘧啶的SP片组成		青蒿琥酯：口服,1次/d,共服3 d	磺胺多辛-乙胺嘧啶：口服,首日单次服用
		5~< 10	25 mg	磺胺多辛250 mg + 乙胺嘧啶12.5 mg
		10~< 25	50 mg	磺胺多辛500 mg + 乙胺嘧啶25 mg
		25~< 50	100 mg	磺胺多辛1 000 mg + 乙胺嘧啶50 mg
		≥ 50	200 mg	磺胺多辛1 500 mg + 乙胺嘧啶75 mg
青蒿琥酯-咯萘啶	片剂,复方制剂,由青蒿琥酯和磷酸咯萘啶组成国内无生产厂家国外剂型包括：片剂：每片青蒿琥酯60 mg + 磷酸咯萘啶 180 mg		口服,1次/d,共服3 d
		5~< 8	青蒿琥酯20 mg + 磷酸咯萘啶60 mg（干混悬剂）
		8~< 15	青蒿琥酯40 mg + 磷酸咯萘啶120 mg（干混悬剂）
		15~< 20	青蒿琥酯60 mg + 磷酸咯萘啶180 mg（干混悬剂）
		20~< 24	青蒿琥酯60 mg + 磷酸咯萘啶180 mg（片剂）
		24~< 45	青蒿琥酯120 mg + 磷酸咯萘啶360 mg（片剂）
		45~< 65	青蒿琥酯180 mg + 磷酸咯萘啶540 mg（片剂）
		≥ 65	青蒿琥酯240 mg + 磷酸咯萘啶720 mg（片剂）

表1

参考文献 33

[1]	World Health Organization. World malaria report 2021[R]. Geneva: WHO, 2021.
[2]	Gao Q. Challenge and response of imported malaria for preventing malaria re-establishment[J]. Chin Trop Med, 2021, 21(1): 1-4. (in Chinese)
	( 高琪. 输入性疟疾对巩固消除疟疾成果防止再传播的挑战和对策[J]. 中国热带医学, 2021, 21(1): 1-4.)
[3]	Feng J, Zhang L, Xia ZG, et al. Malaria elimination in China: an eminent milestone in the anti-malaria campaign and challenges in the post-elimination stage[J]. Chin J Parasitol Parasit Dis, 2021, 39(4): 421-428. (in Chinese)
	( 丰俊, 张丽, 夏志贵, 等. 中国消除疟疾: 重要里程碑意义及消除后的挑战[J]. 中国寄生虫学与寄生虫病杂志, 2021, 39(4): 421-428.)
[4]	Xia ZG, Zhou SS, Tang LH. History, impacts and experience of malaria elimination in China and strategies and prospects after elimination[J]. Infect Dis Inf, 2022, 35(1): 39-45, 59. (in Chinese)
	( 夏志贵, 周水森, 汤林华. 中国消除疟疾的历程、意义、主要经验及消除后策略与展望[J]. 传染病信息, 2022, 35(1): 39-45, 59.)
[5]	Wang XY, Zhang WH. How to strengthen the clinicia’s ability to diagnose and treat malaria after eliminating malaria epidemic in China[J]. J Clin Intern Med, 2022, 39(4): 217-218. (in Chinese)
	( 王新宇, 张文宏. 中国消除疟疾流行后如何加强临床医生疟疾的诊治能力[J]. 临床内科杂志, 2022, 39(4): 217-218.)
[6]	Cao J, Liu YB, Cao YY, et al. Sustained challenge to malaria elimination in China: imported malaria[J]. Chin J Parasitol Parasit Dis, 2018, 36(2): 93-96. (in Chinese)
	( 曹俊, 刘耀宝, 曹园园, 等. 中国消除疟疾的持续挑战: 输入性疟疾[J]. 中国寄生虫学与寄生虫病杂志, 2018, 36(2): 93-96.)
[7]	Feng J, Zhang L, Tu H, et al. From elimination to post-elimination: characteristics, challenges and re-transmission preventing strategy of imported malaria in China[J]. Chin Trop Med, 2021, 21(1): 5-10. (in Chinese)
	( 丰俊, 张丽, 涂宏, 等. 从消除到消除后: 中国输入性疟疾的疫情特征、挑战及防止再传播策略[J]. 中国热带医学, 2021, 21(1): 5-10.)
[8]	World Health Organization. WHO guidelines for malaria[M]. Geneva: WHO, 2021.
[9]	Centers for Disease Control and Prevention. Treatment of malaria: guidelines for clinicians (United States)[EB/OL]. (2020-05-11)[2022-07-01]. https://www.cdc.gov/malaria/resources/pdf/Malaria_Treatment_Guidelines.pdf.
[10]	Lalloo DG, Shingadia D, Bell DJ, et al. UK malaria treatment guidelines 2016[J]. J Infect, 2016, 72(6): 635-649. doi: S0163-4453(16)00047-5 pmid: 26880088
[11]	Health Industry Standard of the People’s Republic of China. Diagnosis of malaria: WS 259—2015[S/OL]. (2015-12-01)[2022-06-23]. http://www.nhc.gov.cn/ewebeditor/uploadfile/2015/12/20151208094408183.pdf. (in Chinese)
	(中华人民共和国卫生行业标准. 疟疾的诊断: WS 259—2015[S/OL]. (2015-12-01)[2022-06-23]. http://www.nhc.gov.cn/ewebeditor/uploadfile/2015/12/20151208094408183.pdf. )
[12]	Health Industry Standard of the People’s Republic of China. Specification for use of antimalarial drugs: WS/T 485—2016[S/OL]. (2016-05-01)[2022-06-23]. http://www.nhc.gov.cn/ewebeditor/uploadfile/2016/05/20160530143429328.pdf. (in Chinese)
	(中华人民共和国卫生行业标准. 抗疟药使用规范: WS/T 485—2016[S/OL]. (2016-05-1)[2022-06-23]. http://www.nhc.gov.cn/ewebeditor/uploadfile/2016/05/20160530143429328.pdf. )
[13]	Feng J, Zhang L, Zhang SS, et al. Malaria epidemiological characteristics in China, 2005—2015[J]. Chin Trop Med, 2017, 17(4): 325-335. (in Chinese)
	( 丰俊, 张丽, 张少森, 等. 全国2005—2015年疟疾疫情分析[J]. 中国热带医学, 2017, 17(4): 325-335.)
[14]	Tu H, Feng J, Zhang L, et al. The analysis of deaths due to malaria in China, 2016[J]. Chin Trop Med, 2018, 18(7): 650-653. (in Chinese)
	( 涂宏, 丰俊, 张丽, 等. 2016年我国疟疾死亡病例分析[J]. 中国热带医学, 2018, 18(7): 650-653.)
[15]	Zhang L, Feng J, Zhang SS, et al. The progress of national malaria elimination and epidemiological characteristics of malaria in China in 2017[J]. Chin J Parasitol Parasit Dis, 2018, 36(3): 201-209. (in Chinese)
	( 张丽, 丰俊, 张少森, 等. 2017年全国消除疟疾进展及疫情特征分析[J]. 中国寄生虫学与寄生虫病杂志, 2018, 36(3): 201-209.)
[16]	Zhang L, Feng J, Zhang SS, et al. Epidemiological characteristics of malaria and the progress towards its elimination in China in 2018[J]. Chin J Parasitol Parasit Dis, 2019, 37(3): 241-247. (in Chinese)
	( 张丽, 丰俊, 张少森, 等. 2018年全国疟疾疫情特征及消除工作进展[J]. 中国寄生虫学与寄生虫病杂志, 2019, 37(3): 241-247.)
[17]	Zhang L, Feng J, Xia ZG, et al. Epidemiological characteristics of malaria and progress on its elimination in China in 2019[J]. Chin J Parasitol Parasit Dis, 2020, 38(2): 133-138. (in Chinese)
	( 张丽, 丰俊, 夏志贵, 等. 2019年全国疟疾疫情特征分析及消除工作进展[J]. 中国寄生虫学与寄生虫病杂志, 2020, 38(2): 133-138.)
[18]	Zhang L, Feng J, Tu H, et al. Malaria epidemiology in China in 2020[J]. Chin J Parasitol Parasit Dis, 2021, 39(2): 195-199. (in Chinese)
	( 张丽, 丰俊, 涂宏, 等. 2020年全国疟疾疫情分析[J]. 中国寄生虫学与寄生虫病杂志, 2021, 39(2): 195-199.)
[19]	Zhang L, Yi BY, Xia ZG, et al. Epidemiological characteristics of malaria in China, 2021[J]. Chin J Parasitol Parasit Dis, 2022, 40(2): 135-139. (in Chinese)
	( 张丽, 易博禹, 夏志贵, 等. 2021年全国疟疾疫情特征分析[J]. 中国寄生虫学与寄生虫病杂志, 2022, 40(2): 135-139.)
[20]	Jiang XH, Huang YX, Ling Y, et al. Clinical epidemiological analysis of imported malaria in Shanghai[J]. Chin J Parasitol Parasit Dis, 2017, 35(2): 150-155. (in Chinese)
	( 蒋旭华, 黄玉仙, 凌云, 等. 上海市输入性疟疾临床流行病学特征分析[J]. 中国寄生虫学与寄生虫病杂志, 2017, 35(2): 150-155.)
[21]	Wang XY, Yang LL, Jiang T, et al. Effects of a malaria elimination program: a retrospective study of 623 cases from 2008 to 2013 in a Chinese County hospital near the China-Myanmar border[J]. Emerg Microbes Infect, 2016, 5(1): e6.
[22]	WHO. Severe malaria[J]. Trop Med Int Health, 2014, 19(Suppl 1): 7-131. doi: 10.1111/tmi.12313_2
[23]	Yang YJ. Research on severe cases of imported falciparum malaria[J]. Chin Trop Med, 2018, 18(7): 662-665. (in Chinese)
	( 杨跃杰. 输入性恶性疟疾重症病例研究[J]. 中国热带医学, 2018, 18(7): 662-665.)
[24]	He ZY, Wu WT, Wang XM, et al. Analysis on the characteristics and risk factors of imported malaria deaths in Beijing[J]. Acta Parasitol Med Entomol Sin, 2021, 28(2): 67-70, 75. (in Chinese)
	( 何战英, 吴文婷, 王小梅, 等. 北京市输入性疟疾死亡病例特征及危险因素分析[J]. 寄生虫与医学昆虫学报, 2021, 28(2): 67-70, 75.)
[25]	Zhang Q, Geng QB, Sun JL, et al. Epidemiological analysis of the deaths of malaria in China, 2005—2014[J]. Chin J Prev Med, 2016, 50(4): 302-305. (in Chinese) doi: 10.3760/cma.j.issn.0253-9624.2016.04.004 pmid: 27029359
	( 张倩, 耿启彬, 孙军玲, 等. 2005—2014年中国疟疾死亡病例流行特征分析[J]. 中华预防医学杂志, 2016, 50(4): 302-305.)
[26]	Su Y, Miao Q, Hu BJ, et al. A case of Plasmodium malariae infection identified by metgenomic next-generation sequencing and literature review[J]. Chin J Clin Infect Dis, 2019, 12(5): 359-361. (in Chinese)
	( 苏逸, 缪青, 王青青, 等. 宏基因二代基因检测技术诊断三日疟一例及文献复习[J]. 中华临床感染病杂志, 2019, 12(5): 359-361.)
[27]	Li RQ, Wang XM, Sun YL, et al. Application of metagenomic next-generation sequencing in the diagnosis of imported malaria[J]. Chin J Parasitol Parasit Dis, 2019, 37(6): 727-729. (in Chinese)
	( 李仁清, 王小梅, 孙玉兰, 等. 宏基因组学二代测序技术在输入性疟疾诊断中的应用[J]. 中国寄生虫学与寄生虫病杂志, 2019, 37(6): 727-729.)
[28]	Zhou SS. Problems in the use of antimalarial drugs and their impacts on malaria elimination in China[J]. Chin Trop Med, 2018, 18(7): 640-642. (in Chinese)
	( 周水森. 我国抗疟药使用存在的问题及其对消除疟疾的影响[J]. 中国热带医学, 2018, 18(7): 640-642.)
[29]	Yu FT, Zhang SF, Chen BH, et al. Evaluation of the diagnostic accuracy of the CareStart^TM glucose-6-phosphate dehydrogenase deficiency rapid diagnostic test among Chinese newborns[J]. J Trop Pediatr, 2020, 66(5): 495-503. doi: 10.1093/tropej/fmaa003
[30]	Hua HY, Sun F, Chen W, et al. Interpretation of WHO management of severe malaria(third edition)[J]. Chin Trop Med, 2018, 18(7): 643-645, 649. (in Chinese)
	华海涌, 孙芳, 陈伟, 等. 世界卫生组织《重症疟疾管理实用手册》(第三版)解读[J]. 中国热带医学, 2018, 18(7):643- 645, 649.)
[31]	Wooldridge G, Nandi D, Chimalizeni Y, et al. Cardiovascular findings in severe malaria: a review[J]. Glob Heart, 2020, 15(1): 75. doi: 10.5334/gh.789 pmid: 33299771
[32]	Phu NH, Day NPJ, Tuan PQ, et al. Concomitant bacteremia in adults with severe falciparum malaria[J]. Clin Infect Dis, 2020, 71(9): e465-e470.
[33]	Liu YY, Lian JS, Huang JR. Two cases of malignant malaria complicated with hemolytic uremic syndrome were treated with blood purification[J]. Chin J Infect Dis, 2016, 34(9): 570. (in Chinese)
	( 刘月英, 连江山, 黄建荣. 血液净化治疗恶性疟疾并发溶血尿毒综合征二例[J]. 中华传染病杂志, 2016, 34(9): 570.)