Kasus Malaria Resistensi

Obat An1-Malaria
Yovita Hartantri
Departemen Ilmu Penyakit Dalam FK UNPAD/RSUP dr. Hasan Sadikin
17 Mei 2022
Kasus
• Laki-laki 37 tahun
• Demam menggigil seFap 48jam (hari sakit ke-4)
• Saat MRS : bawa hasil lab trombosit ↙, IgG dan IgM dengue +
• Hari sakit ke-7 demam (+), riwayat ke Mimika-Timika Papua, 1 bulan di sana
• Hari sakit ke-11 hasil lab ADT : plasmodium falsiparum (pf)
• Dapat terapi Dehidroartemisinin Piperakuin (DHP) dan primakuin
• Follow up hari ke-14 : demam (-), nyeri kepala (+/-), masih ada pf trofozoit

Pertanyaan : apakah gagal terapi? ACT resisten?

 Introduc,on
• Malaria control requires an integrated approach :
• PrevenFon
• Vector control
• Prompt treatment with effecFve anFmalarial drugs

4R

• Resistance
• Recurrence : recrudescence, relapse, reinfecFon

Shibeshi MA et al. An/malarial drug resistance and novel targets for an/malarial drug discovery, Infec/on & Drug Resistance 2020
Recurrence
• is the recurrence of asexual parasitemia following treatment
• in pl. vivax and pl. ovale infections only
• or a new infection
Recurrent falciparum malaria

• Recurrence of P. falciparum malaria can result from

• re-infec(on or
• recrudescence (treatment failure)
• Treatment failure may result from
• drug resistance or
• inadequate exposure to the drug due to
• sub-op'mal dosing,
• poor adherence,
• vomi'ng,
• unusual pharmacokine'cs in an individual, or
• substandard medicines.
It is important to determine from the pa(ent’s history whether he or she vomited the
previous treatment or did not complete a full course of treatment.
The concentra+on-effect rela+onship for an+malarial
drugs, the effect is parasite killing M

red cells behave very differently from their unparasitized c

Emax : maximum parasite killing or
parts. In the patient, the blood concentrations of the anti
maximum parasite
drug are changing reduc5on
constantly, ra5o
and (in vivo)age distri
the parasite
may differ considerably between patients. Ex vivo system
EC50 : 50%
changing of maximum
antimalarial killing that are more biol
concentrations
relevant than theinsimple
(concentra5on blood static drug susceptibility assa
or plasma)
therefore been developed, and measurement of multiplica
hibition can yield valuable information (19). Rodent
Blue : median
capable and range
of sustaining human values forinfections
malaria a have al
hypothe5cal popula5on
developed recently of malaria
(36). Human malaria infections in im
parasites
deficient mice allow PK-PD characterization and thus
useful information in predicting therapeutic responses in p
These laboratory studies have the great advantage that p
Red : distribu5on of average drug levels
from many different locations or with known resistance
FIG 2 The concentration-effect relationship; for antimalarial drugs, the effect can be studied and compared. It is argued below that if t
is parasite killing, which can be measured in different ways. The Emax is the tionship between the standard in vitro susceptibility m
maximum parasite killing that a drug can produce, which translates in vivo into (50% inhibitory concentrations [IC50], IC90, etc.) and
White NJ,
the maximum Pharmacokine/c
parasite & Pharmacodynamic
reduction ratio. The EC50 is the bloodConsidera/on
or plasma con-in An/malarial Dose Op/miza/on, AAC 2013
PK-PD responses in patients with malaria could be charac
centration providing 50% of maximum killing. The median and range values
then this would facilitate dose finding.
Recrudescence

• is the recurrence of asexual parasitemia aCer the treatment of the

infecDon with the same infecDon
• due to incomplete clearance of asexual parasitaemia of the same
genotype(s) that caused the original illness.
• a recrudescent case must be disDnguished from reinfecDon and
relapse, in the case of P. vivax and P. ovale
Relapse

• is the recurrence of asexual parasitemia in Pl. vivax or Pl. ovale

malaria deriving from persisDng liver stages from hypnozoites
• Malaria case aLributed to acDvaDon of hypnozoites of P. vivax or P.
ovale acquired previously
Reinfec,on

• a new infecDon that follows a primary infecDon

• can be disDnguished from recrudescence by the parasite genotype,
which is oCen (but not always) different from that which caused the
iniDal infecDon
Resistance
• The ability of a parasite to survive or mulDply despite properly
administered and dosed medicaDon
• An important marker of resistance is delayed parasite clearance
Dmes.
• A major challenge with assessing anDmalarial efficacy in the era of
combinaDon therapy is that failure may not be observed even when
the parasites are resistant to one of the partner drugs.

Cowell AN, Winzeler. EA. The genomic architecture of An:malarial drug resistance, 2019
Factors that favor of resistance
• higher levels of parasitemia
• decreased blood levels of antimalarials
• decreased patient immunity

Cowell AN, Winzeler. EA. The genomic architecture of An:malarial drug resistance, 2019
 18/5/314/5497442 by guest on 08 May 2022
patients presenting with late recrudescence, or persistent para- atovaquone cause parasites to die in the mosquitos so that

Life cycle plasmodium

sitemia [4]. In addition, patients present with recrudescence ear- they should, in principle, not spread from one person to the
lier following treatment. High-grade resistance is evident when next [10].

Figure 1. The P. falciparum life cycle highlighting the asexual blood stage of infection where antimalarial resistance mutations arise. Infection begins with inoculation
The P. falciparum life cycle highligh:ng the asexual blood stage of infec:on where
of sporozoites by an infected mosquito. Sporozoites infect liver cells, and merozoites are released into the bloodstream, which invade red blood cells (RBCs). During
the asexual blood stage of infection, which is responsible for the clinical manifestations of disease, the parasites undergo maturation and replication with an average
an:malarial
of 109 –1012 parasites per replicationresistance muta:ons
cycle. The infected RBCs rupture, arise.
releasing new merozoites into the bloodstream to begin another cycle of replication. A subset of
parasites becomes gametocytes which can be ingested by another mosquito to continue malaria transmission.

Cowell AN, Winzeler. EA. The genomic architecture of An/malarial drug resistance, 2019
 Mechanisms of resistance to an+malarial drugs in
plasmodium falciparum
• Drug resistance is primarily caused by pl. falciparum
• Pl. falciparum drug resistance malaria originates from chromosome
mutaDons
• Analysis by molecular, geneDc and biochemical approaches has
shown that :
• Impaired Chloroquine uptake by the parasite vacuole is a common
characterisFc of resistant strains. This phenotype is correlated with mutaFons
of the Pfmdr1, Pfcg2 and Pfcrt genes.
• One of four point mutaFons of dihydrofolate reductase (DHFR), the enzyme
target of anFfolates (Pyrimethamine and proguanil) produce a moderate to
high level of resistance to these drugs

Fundam Clin Pharmacol. 2003 Apr; 17 (2): 147-53

Continued…
• Treatment with sulphadoxine-pyrimethamine selects for DHFR variants
• The mechanism of resistance to sulfonamides and sulfones involves
mutaFons of dihydropteroate synthase (DHPS).
• Clones that were resistant to some tradiFonal anFmalarial agents acquired
resistance to new ones at a high frequency (accelerated resistance to mulFple
drugs/ARMD)
• The mechanism of resistance for amino-alcohols (quinine, mefloquine and
halofantrine) are sFll unclear

Fundam Clin Pharmacol. 2003 Apr; 17 (2): 147-53

 Mechanism of resistance
is mostly induced due to enhanced and non-specific efflux which is potentially toxic to the parasite.

Table 1 Summary of Some Antimalarial Drugs, Mechanism of Action, Site of Action, and Mechanism of Resistance
Antimalarial Drug Mechanism of Action Site of Mechanism of Resistance
Action

Antifolates ((pyrimethamine Inhibition of dihydrofolate reductase Cytosol Mutations in dihydrofolate reductase (DHFR)
(PYR) and cycloguanil (CYC)) (DHFR)

Antifolates (sulfadoxine (SDX)) Inhibition dihydropteroate synthetase Cytosol Dihydropteroate synthetase (DHPS)
(DHPS)

Naphthoquinones (Atovaquone Inhibits mitochondrial electron Mitochondria A single point mutation in the cytochrome
(ATQ)) transport b subunit (CYTb) of the bc1 complex

Antibiotics (Clindamycin (CLD) Inhibit protein translation inside the Inside the A point mutation in the apicoplast encoded 23S
and Doxycycline (DOX)) apicoplast apicoplast rRNA (CLD)

Artemisinin (ART) Alkylation of proteins and lipids ER, vesicular Mutation in K13
structures

4- aminoquinolines (CQ, AQ,
PPQ, Mannich base
pyronaridine (PND))
They bind reactive heme and interfere
with its detoxification through
incorporation into chemically inert
hemozoin.
Digestive Point mutations in the transporters PfCRT and
vacuole PfMDR1, increased expression of the
hemoglobinases plasmepsin 2 and 3 (PM2/PM3, in
the digestive vacuole), and might in some instances
involve mutant PfCRT

Shibeshi MA et al, An/malarial Drug Resistance and Novel Targets for An/malarial Drug Discovery,
Infec/on and Drug Resistance 2020
 Gene$c mediators of resistance in pl. falciparum and pl. vivax
Table 1. Commonly used antimalarials and their known genetic mediators of resistance in P. falciparum and P. vivax. SNVs known to be essential
to resistance are highlighted with an asterisk

Antimalarial drug class Mechanism of Specific drugs Genetic mediator(s) of resistance

action P. falciparum P. vivax

chloroquine (CQ) SNVs in pfcrt (K76 T∗); SNVs in

amodiaquine(AQ) pfmdr1 (N86Y∗)

Interfere with heme SNVs in pfcrt (C101F, H97Y, Not well understood;
4-aminoquinolines F145I, M343 L, G353 V);
detoxification piperaquine pvcrt-o amplification
Plasmepsin 2 and 3
(PPQ)
amplifications; pfmdr1 single
copy
Primaquine
4-aminoquinolines Unknown Unknown Unknown
Tafenaquine
DHFR inhibitors SNVs in pfdhfr (S108 N, N51I,
(proguanil, C59R, I164L); amplification of SNVs in pvdhfr
Inhibition of folate pyrimethamine) gtp cyclohydrolase 1
Antifolate drugs
synthesis
Sulfa drugs Inherently resistant
(sulfamethoxazole, SNVs in SNVs in pfdhps due to SNV in pvdhps
sulfadoxine) (V585)
lumefantrine (LMF) Amplification of
SNP (single nucleo:de polymorphisms) or gene amplifica:on. Amplification of pfmdr1
pvmdr1
PfCRT (Pl. falciparum chloroquine resistance
Unclear; thought to transporter
mefloquine (MFQ)gene)
Aryl amino-alcohols
PfMDR1 (Pl. falciparuminterfere
mul:drugwith heme
resistance transporter 1)
Quinine Not clear, involves mediators
detoxification of LMF and MQ resistance;
Not reported
ms4760 microsatellites in
Cowell AN, Winzeler. EA. The genomic architecture of An/malarial drug resistance, 2019
 Primaquine
4-aminoquinolines Unknown Unknown Unknown
316 Cowell and Winzeler Tafenaquine

Genetic mediators of resistance in Pl. falciparum and Pl. vivax

DHFR inhibitors
(proguanil,
SNVs in pfdhfr (S108 N, N51I,
C59R, I164L); amplification of SNVs in pvdhfr
Table 1. Commonly used antimalarials and their known genetic mediators of resistance in P. falciparum and P. vivax. SNVs known to be essential
Inhibition of folate pyrimethamine) gtp cyclohydrolase 1
to resistance
Antifolate are highlighted with an asterisk
drugs
synthesis
Sulfa drugs Inherently resistant
Antimalarial drug class Mechanism of Specific drugs Genetic mediator(s) of resistance
(sulfamethoxazole, SNVs in SNVs in pfdhps due to SNV in pvdhps
action P. falciparum P. vivax
sulfadoxine) (V585)
chloroquine
lumefantrine(CQ)
(LMF) SNVs in pfcrt (K76 T∗); SNVs in Amplification of
Amplification of pfmdr1
amodiaquine(AQ) pfmdr1 (N86Y∗) pvmdr1
Unclear; thought to mefloquine (MFQ)
Aryl amino-alcohols Interfere
interfere with heme SNVs in pfcrt (C101F, H97Y, Not well understood;
4-aminoquinolines Quinine Not clear, involves mediators
detoxification
detoxification F145I, M343 L, G353 V); pvcrt-o amplification
piperaquine of LMF and MQ resistance;
Plasmepsin 2 and 3 Not reported
(PPQ) ms4760 microsatellites in
amplifications; pfmdr1 single
pfnhe-1
copy
Doxycycline Unknown
Inhibition of protein Primaquine
4-aminoquinolines
Antibiotics Unknown Clindamycin
Unknown
SNV in 23S rRNA (A1875C)
Unknown
Not reported
synthesis Tafenaquine

Napthoquinones Inhibits cytochrome DHFR inhibitors

Atovaquone SNVs in pfdhfr (S108 N, N51I,
(proguanil, SNV
C59R,inI164L);
cyt-b (Y268S/C/N)
amplification of Not
SNVsreported
in pvdhfr
bc1 complex
Inhibition of folate pyrimethamine) gtp cyclohydrolase 1
Antifolate drugs
Artemisinin compounds synthesis
Causes oxidative Artemisinin,
Sulfa drugs artemether, SNVs in kelch13 (C580Y) Inherently
Not resistant
reported
stress DHA
(sulfamethoxazole, SNVs in SNVs in pfdhps due to SNV in pvdhps
sulfadoxine) (V585)
Cowell AN, Winzeler. EA. The genomic lumefantrine
architecture(LMF)
of An:malarial drug resistance, 2019 Amplification of
Amplification of pfmdr1
Known genetic mediators of resistance
Unclear; thought to mefloquine (MFQ) then emerged in other countries in Asia,pvmdr1
South America and
finally Africa over the course of 30 years [15, 16]. Resistance is
4-Aminoquinolines
Aryl amino-alcohols interfere with heme Quinine Not clear, involves mediators
primarily determined by mutations in pfcrt, a gene that encodes
Key finding : 10 years of surveillance
Data from 66,000 pa5ents worldwide

- ACTs remain effec5ve in curing pl. falciparum

- High treatment failure rate were reported,
policy changes have been made or are ongoing
- In 4 countries in Greater Mekong subregion
(Cambodia, Laos, Thailand, Vietnam) high
treatment failure rates were detected, at least 2
other ACT op5ons that could effec5vely treat pl.
falciparum malaria
- Overall average efficacy rates for these 3
medicines were consistently high :
- AL (98%)
- AS– AQ (98.4%)
- DHA – PPQ (99.4%)
An+malaria drug are broadly categorized into 3 types :

• Aryl Amino Alcohol compounds :

• Quinine, Quinidine
• Halofantrine, Lumefantrine
• Chloroquine, Amodiaquine, Mefloquine, Cycloquine, etc
• AnDfolate compounds :
• Proguanil
• Pyrimethamine
• Trimethoprim, etc
• Artemisinin compounds :
• Artemisinin, Dihydroartemisinin
• Artesunat, Artemether, Arte-ether, etc
An,malarial drugs target :
• Asexual erythrocyDc stages (blood schizonDcidal drugs)
• Fast acFng (chloroquine, quinine, mefloquine)
• Slow acFng (pyrimethamine, sulphonamides and sulphone)
• Tissue schizonDcidal drugs target the hypnozoites (dormant stage of
the parasite) in the liver whereas gametocytocidal drugs destroy
sexual erythrocyDc
• Sporontocides prevent or inhibit the formaDon of malarial oocysts
and sporozoites in the infected mosquito
The timeline between the introduction of the main antimalarial
drugs and the first case of emergence of resistance

Duru V et al. Am J Trop Med Hyg, 2016

Chloroquine Sulfadoxine
Pyrimetamine
• Introduced in 1967
(Thailand)
• Introduced in 1945 • 1 st case of resistance : 1967
• 1st case of resistance : 1957 • South East Asia
• 4 lokasi • Afrika, meluas di akhir 1990
• 1957 : perbatasan Thai – Cambodian
• 1960 : Venezuela dan Columbia
• 1970 : Papua New Guinea
• 1978 : Afrika (Kenya, Tanzania)
1983 : Sudan, Uganda, Zambia, Malawi
Artemisinin Quinine
• Introduced in 1979 (in Chinese • Introduced in 1632 (Peru)
medical journal) • Resistance 1910
• Resistance 2009
• Thai-Cambodia border
• South East Asia
• Very potent and effecAve when used
in combinaAon with other malaria
medicine
• Combining with drug that has longer
half life was found to improve the
efficacy of the artemisinin
Artemisinin partial resistance
• is defined as delayed parasite clearance
• it represents a parDal resistance that has affected only ring-stage
parasites
• sDll able to clear their infecDons following treatment with an ACT with
an effecDve partner drug or with an artesunate treatment lasDng
seven days.
• several mutaDons in the PfKelch13 (K13) propeller domain were
found to be associated with delayed parasite clearance in vitro and in
vivo.

Global Malaria Programme, Artemisinin Resistance and ACT Efficacy, 2018

Artemisinin resistance
• Some pfKelch13 mutaDons associated with delayed parasite clearance
have been also reported in South America and Papua New Guinea.
• pfKelch13 mutaDons have been observed in Africa, but not associated
with artemisinin resistance.
• The mode of acDon of artemisinins is sDll not fully understood
• Even though artemisinin derivaDves have been shown to
• cause oxidaFve stress and
• probably impacFng on mulFple targets in the parasite

Global Malaria Programme, Artemisinin Resistance and ACT Efficacy, 2018

Resistance (WHO 2021)

• AnDmalarial drug resistance is the ability of a parasite strain to survive

and/or mulDply despite administraDon and absorpDon of an
anDmalarial drug given in doses equal to or higher than those usually
recommended, provided that drug exposure is adequate.
• Resistance to anDmalarial drugs arises because of selecDon of
parasites with geneDc changes (mutaDons or gene amplificaDons)
that confer reduced suscepDbility.
• Resistance has been documented to all classes of anDmalarial
medicines, including the artemisinin derivaDves, and it is a major
threat to malaria control.
WHO Guidelines for Malaria - 2022 (Recurrent Falciparum Malaria)
Con,nued…
• Widespread inappropriate use of anDmalarial drugs exerts a strong
selecDve pressure on malaria parasites to develop high levels of
resistance.
• Resistance can be prevented, or its onset slowed considerably by
• combining anFmalarial drugs with different mechanisms of acFon and
• ensuring high cure rates through full adherence to correct dose regimens.
• If different drugs with different mechanisms of resistance are used
together, the emergence and spread of resistance should be slowed.
 Monitoring efficacy and safety of an+malarial drug and
resistance
• RouDne surveillance
• WHO promotes universal coverage with diagnosFc tesFng and anFmalarial
treatment and strengthened malaria surveillance system
• The “test”, “track”, “treat” iniFaFve
• TherapeuDc efficacy
• Assessing clinical and parasitological outcome of treatment for at least 28
days aker the start of adequate treatment
• PCR genotyping should be used to disFnguish between recrudescence and
new infecFons
• AnFmalarial medicine should be changed if the total treatment failure
proporFon is ≥ 10%, as assessed in vivo by monitoring therapeuFc efficacy

WHO Guideline for Malaria - 2022

 Clinical and parasitological assessment of
therapeu5c efficacy should include:
• confirmaDon of the quality of the anDmalarial medicines tested
• molecular genotyping to disDnguish between re-infecDons and
recrudescence and to idenDfy geneDc markers of drug resistance;
• studies of parasite suscepDbility to anDmalarial drugs in culture; and
• measurement of anDmalarial drug levels to assess exposure in cases
of slow therapeuDc response or treatment failure

WHO Guidelines for Malaria - 2022 (Recurrent Falciparum Malaria)

 Failure within 28 days
• The recommended second-line
treatment is an alternaFve ACT known
to be effecFve in the region
• 7-day treatment regimens (with
artesunate or quinine with +
tetracycline, or doxycycline or
clindamycin) is likely to be poor if
treatment is not directly observed;
• These regimens are no longer generally
recommended.
WHO Guidelines for Malaria - 2022 (Recurrent Falciparum Malaria)
Failure aIer 28 days
• May be due to either recrudescence or
a new infecFon.
• The disFncFon can be made only by
PCR genotyping of parasites from the
iniFal and the recurrent infecFons.
• PCR is not rouFnely used, all presumed
treatment failures aker 4 weeks of
iniFal treatment should be considered
new infecFons and be treated with the
first-line ACT.
 Strong recommenda5on for ACT
• Treat children and adults with uncomplicated P. falciparum malaria
(except pregnant women in their first trimester) :
• artemether + lumefantrine
• artesunate + amodiaquine
• artesunate + mefloquine
• dihydroartemisinin + piperaquine
• artesunate + sulfadoxine–pyrimethamine (SP)
• artesunate + pyronaridine
(currently unGRADEd, anFcipated to be updated in 2022)
ACT failure is not only due to artemisinin resistance, but also to the failure of
partner drugs

WHO Guidelines for Malaria – 2022

Nsanzabana C, Resistance to ACTs : Do Not Forget The Partner Drug, Tropical Medicine & Infec:ous Disease, 2019
Core Principles of Malaria Case Management
• Early diagnosis and prompt effecDve treatment of malaria
→ within 24-48 h of the onset of symptom
• RaDonal use of anDmalaria agents
• CombinaDon therapy
• Appropriate weight-based dosing

WHO Guideline Malaria - 2015

Kasus
• Follow up :
• Diberi primakuin selama 14 hari
• Keluhan (-)

• Pertanyaan :
• Apakah mixed malaria?
• Apakah gagal terapi?
• Apakah recrudescence?
• Apakah koinfeksi dengan dengue fever?
Penilaian kasus :
• Riwayat pengobatan :
apakah obat dimuntahkan atau diminum tetapi Adak tuntas?
• Rekuren dalam 4 minggu, diperAmbangkan sebagai kegagalan terapi.
• Bila memungkinkan, bedakan rekrudensi dengan reinfeksi, meskipun
demam menurun dan parasitemia berkurang.
• Perlu dilakukan pemeriksaan mikroskopik atau RDT berbasis LDH, dengan
tes berbasis P. falciparum his/dine-rich protein-2 (PfHRP2)-mungkin akan
tetap posiAf dalam beberapa minggu setelah infeksi awal bahkan tanpa
rekrudensi.
• Kegagalan terapi kadang Adak diketahui bila Adak ditanyakan secara ruAn.
Ringkasan

• Resistensi obat anDmalaria telah terjadi dan mengancam upaya untuk

melakukan pengendalian malaria di dunia
• Pl. falsiparum dan pl. vivax sebagai penyebab utama penyakit malaria
telah berkembang menjadi resisten hampir di semua obat anD-
malaria.
• Perlu monitoring secara ruDn terhadap efikasi obat anD-malaria untuk
memasDkan efekDvitas obat dalam tatalaksana kasus dan deteksi
awal resistensi
Terimakasih