SEVERE MALARIA I.V. ARTESUNATE TREATMENT CASE REPORTING FORM For Belgium : Dr Jan Clerinx, Institute of Tropical Medicine () Please send this form by mail - You may save the form on your computer for your own reference. Name Clinic Patient ID of local site: ……. …….. Section 1 Demographic and patient data – Date of presentation to clinic/hospital (format: dd-mm-yyyy) Month/Year of birth (format: mm-yyyy) Sex M / F Country of permanent residence Patient Status European resident / Immigrant Country where infection was acquired Chemoprophylaxis Yes / No Compliance Yes / No Purpose of travel VFR / Tourism / Business / Other Pre-treatment criteria of severe malaria Hyperparesitaemia (>10% of RBC according to WHO definition or >500 000/µl) Anaemia (Hb <8 mg/dl) (tick at least one): Hyperparesitaemia (>4% of RBC Very low platelet count (PLT < 20.000/ml) or >200 000/µl) Spontaneous bleeding, DIC Cerebral malaria (obnobulation or Hypoglycaemia (<40 mg/dl) coma) Acidosis (pH <7.25) Convulsions Jaundice (bilirubin >3 mg/dl or >50µmol/l) Acute renal failure (urine output ALAT/ASAT >3 x UNL <400/24h or creatine >2,5 mg/dl) Respiratory failure or ARDS Circulatory collapse (Shock) Significant pre-existing comorbidities of the patient (e.g. functional asplenism, HIV coinfection…) Section 2 Yes / No Malaria Treatment regimen First line Treatment? – Date: Day 1= Day of Dx and start of first line Tx (dd/mm/yy) Administered anti-malarial Start of End of Dosage per dose substances administration administration (mg) Drug 1: Drug 2 : Drug 3 : Drug 4 : Additional/supportive treatment/drugs: If IV Artesunate is used, please specify source MALACEF Other (specify)……………… of drug: Section 3 Efficacy of treatment and Duration of inpatient ICU treatment – clinical outcome (days): Parasitemia % of RBC’s or parasites/µL
SEVERE MALARIA I.V. ARTESUNATE TREATMENT CASE REPORTING FORM For Belgium : Dr Jan Clerinx, Institute of Tropical Medicine () Please send this form by mail - You may save the form on your computer for your own reference. Name Clinic Patient ID of local site: ……. …….. Section 1 – Demographic and patient data Date of presentation to clinic/hospital (format: dd-mm-yyyy) Month/Year of birth (format: mm-yyyy) Sex M / F Country of permanent residence Patient Status European resident / Immigrant Country where infection was acquired Chemoprophylaxis Yes / No Compliance Yes / No Purpose of travel VFR / Tourism / Business / Other Pre-treatment criteria of severe malaria according to WHO definition (tick at least one): Hyperparesitaemia (>10% of RBC or >500 000/µl) Hyperparesitaemia (>4% of RBC or >200 000/µl) Cerebral malaria (obnobulation or coma) Convulsions Acute renal failure (urine output <400/24h or creatine >2,5 mg/dl) Respiratory failure or ARDS Circulatory collapse (Shock) Anaemia (Hb <8 mg/dl) Very low platelet count (PLT < 20.000/ml) Spontaneous bleeding, DIC Hypoglycaemia (<40 mg/dl) Acidosis (pH <7.25) Jaundice (bilirubin >3 mg/dl or >50µmol/l) ALAT/ASAT >3 x UNL Significant pre-existing comorbidities of the patient (e.g. functional asplenism, HIV coinfection…) Section 2 – Malaria Treatment regimen First line Treatment? Yes / No Date: Day 1= Day of Dx and start of first line Tx (dd/mm/yy) Administered anti-malarial substances Start of administration End of administration Dosage per dose (mg) Drug 1: Drug 2 : Drug 3 : Drug 4 : Additional/supportive treatment/drugs: If IV Artesunate is used, please specify source of drug: MALACEF Other (specify)……………… Section 3 – Efficacy of treatment and clinical outcome Duration of inpatient ICU treatment (days): Parasitemia % of RBC’s or parasites/µL