National guidelines for malaria treatment in Democratic Republic of the Congo: A critical appraisal

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Abstract CONTEXT AND OBJECTIVESThe fight against malaria is threatened by the emergence and expansion ofPlasmodium falciparumresistance to antimalarial drugs, to the point of questioning treatment patterns drawn by control programs. The objective of this work was to do a critical appraisal of the national guidelines for the treatment of malaria in the Democratic Republic of the Congo.METHODSTo estimate the selective pressure that leads to the emergence ofP. falciparumresistance to antimalarials, a cross-sectional survey was conducted on antimalarials in circulation in pharmacies in Kinshasa. Anex vivoevaluation of theP. falciparumresistance to antimalarial drugs and the analysis of molecular markers of Sulfadoxine-pyrimethamine resistance were conducted in the provinces of Kinshasa and Kongo Central during 2014 and 2015.RESULTS.The following antimalarial drugs were found in 404 pharmacies: Artemisinin-based combination therapies 88.1%, quinine 80.9%, Sulfadoxine-Pyrimethamine 56.4%, oral artemisinin-based monotherapies 23.0% and traditional medicine 30.2%. Artemether-lumefantrine combinations were the most frequently dispensed drugs (93% of pharmacies). The decrease in the susceptibility ofP. falciparumisolates to antimalarials was as follows: chloroquine 65.7%, quinine 52.6%, monodesethylamodiaquine 25%, mefloquine ~ 45%, dihydroartemisinin 1.3%, piperaquine 1.6%, and doxycycline 4.3%. No isolates were found to be lumefantrine-resistant. The prevalence of mutations was high inpfdhfr(N51I: 98.5%, C59R: 88.2%, and S108N: 99.4%) andpfdhps(A437G: 97.8%). ThepfdhpsA581G,pfdhpsK540E,pfdhfrI164L, andpfdhpsA613S mutations were 14%, 17.5%, 0.1%, and 0.6%, respectively.CONCLUSIONThese findings show a highex vivoresistance ofP. falciparumto quinine, the antimalarial that plays an important role in the fight against malaria in the DRC. The present work highlights the complexity of the inappropriate antimalarials distribution. This shows the lack of regulation in the distribution system, potentially affecting the dynamics of resistance.

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