Treatment of Malaria with Asexual Parasitaemia and One or More Features of Severity
When malaria presents with confirmed asexual parasitaemia alongside any clinical or laboratory indicator of severe disease, the management approach changes substantially. This protocol addresses that specific situation, where standard outpatient treatment is insufficient.
Features That Define This Scenario
- Impaired consciousness — Glasgow coma score <11 (adults) or Blantyre coma score <3 (children)
- Prostration, or more than two convulsions within 24 hours
- Metabolic acidosis — base deficit >8 mEq/L, bicarbonate <15 mmol/L, or venous lactate ≥5 mmol/L
- Hypoglycaemia — blood glucose <2.2 mmol/L
- Severe anaemia — haemoglobin ≤5 g/dL (children) or <7 g/dL (adults)
- Renal impairment — creatinine >265 µmol/L
- Jaundice — bilirubin >50 µmol/L
- Pulmonary oedema — oxygen saturation <92% on room air
- Significant bleeding, shock, or hyperparasitaemia (>10% P. falciparum)
Treatment Approach
Management starts with parenteral antimalaria therapy, maintained until the patient is stable enough to tolerate oral treatment — at which point a specific oral course completes the regimen. The protocol also accounts for differences in dosing between patient subgroups.
Complete agent selection, dosing stratification, and the oral transition regimen are detailed in the full protocol below.
References
- Severe falciparum malaria: For epidemiological purposes, severe falciparum malaria is defined as one or more of the following, occurring in the absence of an identified alternative cause and in the presence of P. falciparum asexual parasitaemia.
- Impaired consciousness: A Glasgow coma score < 11 in adults or a Blantyre coma score < 3 in children.
- Multiple convulsions: More than two episodes within 24 h.
- Hypoglycaemia: Blood or plasma glucose < 2.2 mmol/L (< 40 mg/dL).
- Hyperparasitaemia: P. falciparum parasitaemia > 10%.
- Adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women) should be treated with intravenous or intramuscular artesunate for at least 24 h and until they can tolerate oral medication.
- Once a patient has received at least 24 h of parenteral therapy and can tolerate oral therapy, treatment should be completed with 3 days of an ACT.
- Children weighing < 20 kg should receive a higher dose of artesunate (3 mg/kg bw per dose) than larger children and adults (2.4 mg/kg bw per dose) to ensure equivalent exposure to the drug.
- After initial parenteral treatment, once the patient can tolerate oral therapy, it is essential to continue and complete treatment with an effective oral antimalarial drug by giving a full course of effective ACT (artesunate + amodiaquine, artemether + lumefantrine or dihydroartemisinin + piperaquine).