Treatment of severe malarial infection
Seek expert advice.
Treatment should be initiated without delay in patients with proven or strongly suspected malaria.
Treatment includes the following:
Quinine:
- severe infection should be treated with intravenous quinine, especially in the light of considerable worldwide chloroquine resistance
- is the first line antimalarial drug used in severe infection in UK
- oral quinine therapy should be started when the patient is well enough to take oral medication
- quinine treatment should always be followed by a second drug - doxycycline or clindamycin (1)
- Artemisinins
- used only on adults on expert advice
- acts on the ring form of the parasite and reduces the parasite burden rapidly
- it is available as water soluble intravenous formulation and as rectal formulation (when IV therapy cannot be used)
- IV Artesunate can be obtained from specialist tropical disease centers in London and Liverpool
- Artesunate can be considered instead or in addition to quinine in
- patients with parasite counts over 20%,
- very severe disease
- deterioration on optimal doses of quinine
- cardiovascular disease that increases the risks from quinine (1)
- Supportive management
- since the possibility of patients with severe or complicated malaria deteriorating rapidly, all patients should be managed in a high dependency unit.
- Transfer to an Intensive care unit might be necessary for the following patients:
- with severe acidosis
- pulmonary oedema/acute respiratory distress syndrome
- complicated fluid balance problems or renal impairment
- those deteriorating despite appropriate treatment (1)
- hypoglycaemia should be managed with intravenous glucose (infusion of 10% dextrose) if oral intake is poor; blood glucose should be monitored regularly throughout the illness, and certainly while quinine is being given (1)
- in cerebral malaria intubation and ventilation is usually indicated
- intravenous mannitol may have a role to play in the reduction of cerebral oedema
- in situations where there is a very high parasitaemia (>30% red blood cells parasitized) or >10% parasitaemia and other manifestations of severe disease - exchange transfusion may be indicated after discussion with an expert (1)
- After treatment, a single dose of Fansidar should be considered
Emergency standby treatment should be recommended for those taking chemoprophylaxis and visiting remote areas where they are unlikely to be within 24 hours of medical attention (3)- see linked item
Notes:
- there is evidence from a randomised controlled trial that parenteral artesunate, reduced risk of mortality and hypoglycaemia more than quinine in patients with severe falciparum malaria (2)
The summary of product characteristics must be consulted before prescribing the drugs prescribed.
Reference: