Treatment Guidelines for Malaria

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The treatment of choice for non-falciparum malaria is a 3-day course of oral chloroquine, to which only a limited proportion of P. vivax strains have gained resistance. Dormant parasites (hypnozoites) persist in the liver after treatment of P. vivax or P. ovale infection: the only currently effective drug for eradication of hypnozoites is primaquine. This must be avoided or given with caution under expert supervision in patients with glucose-6-phosphate dehydrogenase deficiency (G6PD), in whom it may cause severe haemolysis. Uncomplicated P. falciparum malaria can be treated orally with quinine, atovaquone plus proguanil (Malarone _) or co-artemether (Riamet_); quinine is highly effective but poorly tolerated in prolonged dosage and is always supplemented by additional treatment, usually with oral doxycycline. 

ALL patients treated for P. falciparum malaria should be admitted to hospital for at least 24 h, since patients can deteriorate suddenly, especially early in the course of treatment. Intravenous artesunate reduces high parasite loads more rapidly than quinine and is more effective in treating severe malaria in selected situations.

Falciparum malaria in pregnancy is more likely to be severe and complicated: the placenta contains high levels of parasites. Stillbirth or early delivery may occur and diagnosis can be difficult if parasites are concentrated in the placenta and scanty in the blood. The treatment of choice for falciparum malaria in pregnancy is quinine; doxycycline is contraindicated in pregnancy but clindamycin can be substituted for it, and is equally effective. Primaquine (for eradication of P. vivax or P. ovale hypnozoites) is contraindicated in pregnancy; after treatment for these infections a pregnant woman should take weekly chloroquine prophylaxis until after delivery when hypnozoite eradication can be considered.

There are no specific symptoms of malaria: most patients complain of fever, headache and general malaise.6 Gastrointestinal disturbances, jaundice or respiratory symptoms occasionally occur and are often responsible for misdiagnosis. Most missed malaria infections are erroneously diagnosed as non-specific viral infections, influenza, gastroenteritis or hepatitis.

If there is clinical suspicion of malaria, but initial blood films are negative, repeat films should be examined after 12e24 h and again after a further 24 h. Thrombocytopenia, in particular, is highly suggestive of malaria in non-immune adults and children, both in falciparum and non-falciparum malaria.

Major features of severe or complicated falciparum malaria in adults

  • Impaired consciousness or seizures
  • Renal impairment (oliguria <> 265mmol/l)
  • Acidosis (pH <>
  • Hypoglycaemia (<2.2>
  • Pulmonary oedema or acute respiratory distress syndrome (ARDS)
  • Haemoglobin _ 8 g/dL
  • Spontaneous bleeding/disseminated intravascular coagulation
  • Shock (algid malaria e BP <>
  • Haemoglobinuria (without G6PD deficiency)

Assessment of the patient should include careful clinical evaluation and review of investigations for the features of severe malaria detailed below. A full blood count, urea and electrolytes, liver function tests and blood glucose should be done routinely. In ill patients, blood gases, blood culture, lactate and clotting studies should also be performed. Urine dipstick and culture, stool culture and chest X-ray may be appropriate. Lumbar puncture to exclude meningitis should be considered in febrile patients with impaired consciousness or repeated seizures.

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