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

Abstract

CONTEXT AND OBJECTIVES The fight against malaria is threatened by the emergence and expansion of Plasmodium falciparum resistance 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. METHODS To estimate the selective pressure that leads to the emergence of P. falciparum resistance to antimalarials, a cross-sectional survey was conducted on antimalarials in circulation in pharmacies in Kinshasa. An ex vivo evaluation of the P. falciparum resistance 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 of P. falciparum isolates 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 in pfdhfr (N51I: 98.5%, C59R: 88.2%, and S108N: 99.4%) and pfdhps (A437G: 97.8%). The pfdhps A581G, pfdhps K540E, pfdhfr I164L, and pfdhps A613S mutations were 14%, 17.5%, 0.1%, and 0.6%, respectively. CONCLUSION These findings show a high ex vivo resistance of P. falciparum to 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.