Treatment of Malaria with Asexual Parasitaemia and Features of Severity

Patients with confirmed malaria and asexual parasitaemia who present with one or more of the following severity features require immediate assessment and prompt parenteral treatment. The threshold for any single criterion is sufficient to classify the episode as severe.

Severity Criteria

Impaired consciousness GCS < 11 in adults; Blantyre < 3 in children

Prostration Inability to sit or stand unaided

Repeated convulsions More than 2 episodes within 24 h

Metabolic acidosis Base deficit > 8 mEq/L or bicarbonate < 15 mmol/L or lactate ≥ 5 mmol/L

Hypoglycaemia Blood glucose < 2.2 mmol/L

Severe anaemia Hb ≤ 5 g/dL in children; < 7 g/dL in adults

Renal impairment Creatinine > 265 µmol/L

Jaundice Bilirubin > 50 µmol/L

Pulmonary oedema Oxygen saturation < 92% on room air

Significant bleeding or shock

Hyperparasitaemia P. falciparum parasitaemia > 10%

Treatment Approach

The initial treatment relies on parenteral artemether administered intramuscularly, continuing until oral therapy can be tolerated, at which point a complete course of oral artemisinin-based combination therapy is required to finish treatment.

Specific dosing, timing of transition, and oral ACT selection are detailed in the full protocol →

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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%.
If artesunate is not available, artemether should be used in preference to quinine for treating children and adults with severe malaria.
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).

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