Treatment of Malaria with Asexual Parasitaemia and One or More Features of Severity

This protocol covers malaria presenting with confirmed asexual parasitaemia alongside at least one defined feature of severe disease.

Severity Criteria

One or more of the following features defines this clinical presentation:

Impaired consciousness — Glasgow Coma Score < 11 in adults; Blantyre Coma Score < 3 in children
Prostration
More than two convulsions within 24 hours
Metabolic acidosis — base deficit > 8 mEq/L, plasma bicarbonate < 15 mmol/L, or venous lactate ≥ 5 mmol/L
Hypoglycaemia — blood glucose < 2.2 mmol/L
Severe anaemia — haemoglobin ≤ 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
P. falciparum hyperparasitaemia > 10%

Treatment Approach

Management involves parenteral quinine administered intravenously. The full protocol details the dosing sequence, rate requirements, criteria for dose adjustment, and the conditions under which oral therapy may be introduced.

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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%

Quinine is retained as an option for treating severe malaria when artesunate or artemether is not available or is contraindicated.

Studies of pharmacokinetics show that a loading dose of quinine (20 mg salt/kg bw, twice the maintenance dose) provides therapeutic plasma concentrations within 4 h.

The maintenance dose of quinine (10 mg salt/kg bw) is administered at 8-h intervals, starting 8 h after the first dose.

If there is no improvement in the patient's condition within 48 h, the dose should be reduced by one third, i.e. to 10 mg salt/kg bw every 12 h.

Each dose of parenteral quinine must be administered as a slow, rate-controlled infusion (usually diluted in 5% dextrose and infused over 4 h).

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