Are national treatment guidelines for falciparum malaria in line with WHO recommendations and is antimalarial resistance taken into consideration? - A review of guidelines in non-endemic countries

Artesunate-Nanoliposome-TPP, a Novel Drug Delivery System That Targets the Mitochondria, Attenuates Cisplatin-Induced Acute Kidney Injury by Suppressing Oxidative Stress and Inflammatory Effects

Background

Acute kidney injury (AKI) is a syndrome, posing a substantial healthcare burden. The pathological basis of AKI is associated with inflammation and oxidative stress which cause additional damage to mitochondria. Artesunate (ATS) is a derivative of artemisinin isolated from Artemisia annua L. that is an effective treatment for malaria and favored for the prevention and treatment of kidney diseases. However, there are still challenges related to its efficacy, including poor water solubility, limited oral bioavailability and short half-life. Liposome-based nanoparticles are used for drug delivery due to their ideal biocompatibility and their ability to improve the bioavailability of specific drugs and enhance drug efficacy.

Methods

In this study, a novel TPP-based natural ATS-nanoliposome, namely T-A-Ls, was applied for the treatment of AKI. ATS was encapsulated with or without triphenylphosphonium (TPP)-modified nanoliposomes. AKI was induced by cisplatin in C57BL/6J mice and a cisplatin-induced injury model was generated in HK-2 cells in vitro. Blood urea nitrogen (BUN), serum creatinine (Scr) measurements and section staining were utilized to assess renal protective effect of T-A-Ls. Inflammatory-related factors and proteins were quantified via Elisa, Immunofluorescence and Western Blot (WB). The anti-mitochondrial oxidative stress effect of T-A-Ls was determined by ROS, JC-1 and oxygen consumption rate (OCR) kits. Immunohistochemistry and WB were conducted to measure associated protein expressions. In vivo biodistribution and the concentration of T-A-Ls in kidney were also explored.

Results

T-A-Ls exhibited good oxidative resistance, preferential renal uptake, mitochondrial targeting, and it ameliorated kidney injury in cisplatin-induced AKI mice. Mitochondrial dysfunction, ATP production and respiratory capacity were improved in damaged HK-2 cells; ROS content decreased while mitochondrial membrane potential recovered. T-A-Ls exerted renal protection by inhibiting inflammation and reducing oxidative stress; these effects were mediated by a downregulation in the expression of RAGE and iNOS and an upregulation in both Nrf2 and HO-1.

Conclusion

T-A-Ls could improve the delivery of ATS to the kidney, offering a promising avenue to treat AKI.

The immunity modulation of transforming growth factor-β in malaria and other pathological process

The main causative agent of malaria in humans is Plasmodium falciparum, which is spread through biting Anopheles mosquitoes. Immunoregulation in the host involving the pleiotropic cytokine transforming growth factor-β (TGF-β) has a vital role in controlling the immune response to P. falciparum infection. Based on a search of the published literature, this study investigated the correlation between malaria and immune cells, specifically the role of TGF-β in the immune response. The studies analyzed showed that, when present in low amounts, TGF-β promotes inflammation, but inhibits inflammation when present in high concentrations; thus, it is an essential regulator of inflammation. It has also been shown that the quantity of TGF-β produced by the host can influence how badly the parasite affects the host. Low levels of TGF-β in the host prevent the host from being able to manage the inflammation that Plasmodium causes, which results in a pathological situation that leaves the host vulnerable to fatal infection. Additionally, the amount of TGF-β fluctuates throughout the host's Plasmodium infection. At the beginning of a Plasmodium infection, TGF-β levels are noticeably increased, and as Plasmodium multiplies quickly, they start to decline, hindering further growth. In addition, it is also involved in the growth, proliferation, and operation of various types of immune cell and correlated with levels of cytokines associated with the immune response to malaria. TGF-β levels were positively connected with the anti-inflammatory cytokine interleukin-10 (IL-10), but negatively correlated with the proinflammatory cytokines interferon-γ (IFN-γ) and IL-6 in individuals with severe malaria. Thus, TGF-β might balance immune-mediated pathological damage and the regulation and clearance of infectious pathogens. Numerous domestic and international studies have demonstrated that TGF-β maintains a dynamic balance between anti-inflammation and pro-inflammation in malaria immunity by acting as an anti-inflammatory factor when inflammation levels are too high and as a pro-inflammatory factor when inflammation levels are deficient. Such information could be of relevance to the design of urgently needed vaccines and medications to meet the emerging risks associated with the increasing spread of malaria and the development of drug resistance.

Prescription patterns and compliance with World Health Organization recommendations for the management of uncomplicated and severe malaria: A prospective, real-world study in sub-Saharan Africa

BACKGROUND

This study aimed to evaluate the gap between guidelines and local clinical practice for diagnosis and treatment of uncomplicated and severe malaria, the patient characteristics, diagnostic approach, treatment, and compliance to standard guideline recommendations.

METHODS

This was a multicentre, observational study conducted between October 2020 and March 2021 in which patients of all ages with symptoms suggestive of malaria and who visited a healthcare facility were prospectively enrolled in six countries in sub-Saharan Africa (The Democratic Republic of the Congo, Mozambique, Nigeria, Rwanda, The United Republic of Tanzania, and Zambia).

RESULTS

Of 1001 enrolled patients, 735 (73.4%) patients had confirmed malaria (based on overall judgment by investigator) at baseline (uncomplicated malaria: 598 [81.4%] and severe malaria: 137 [18.6%]). Of the confirmed malaria patients, 533 (72.5%) were administered a malaria rapid diagnostic test. The median age of patients was 11 years (range: 2 weeks-91 years) with more patients coming from rural (44.9%) than urban (30.6%) or suburban areas (24.5%). At the community level, 57.8% of patients sought advice or received treatment for malaria and 56.9% of patients took one or more drugs for their illness before coming to the study site. In terms of early access to care, 44.1% of patients came to the study site for initial visit ≥ 48 h after symptom onset. In patients with uncomplicated malaria, the most prescribed treatments were artemisinin-based combination therapy (ACT; n = 564 [94.3%]), primarily using artemether-lumefantrine (82.3%), in line with the World Health Organization (WHO) treatment guidelines. In addition, these patients received antipyretics (85.6%) and antibiotics (42.0%). However, in those with severe malaria, only 66 (48.2%) patients received parenteral treatment followed by oral ACT as per WHO guidelines, whereas 62 (45.3%) received parenteral treatment only. After receiving ambulatory care, 88.6% of patients with uncomplicated malaria were discharged and 83.2% of patients with severe malaria were discharged after hospitalization. One patient with uncomplicated malaria having multiple co-morbidities and three patients with severe malaria died.

CONCLUSIONS

The findings of this study suggest that the prescribed treatment in most patients with uncomplicated malaria, but not of those with severe malaria, was in alignment with the WHO recommended guidelines.

Chloroquine-Induced Psychosis: A Case Report

The use of antimalarial drugs for prophylaxis is a widespread practice while traveling to underdeveloped nations, particularly those with a high malaria prevalence. Chloroquine is still one of the most commonly recommended antimalarials, either alone or in combination with others, for prophylaxis. However, its increased use over the past few decades has been associated with many adverse effects, including headaches, dizziness, vomiting, and diarrhea, as well as neuropsychiatric symptoms such as psychosis. Here, we discuss the case of a 30-year-old Asian man who, after starting a 500-milligram (mg) prophylactic dosage of chloroquine per week, developed psychotic symptoms. This case highlights the need to use chloroquine and other antimalarials with care, especially when beginning as a prophylactic measure with the lowest suggested dosage.