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Guidelines for the treatment of malaria – 2 edition

treatment in the hospital). Further evidence concerning the rectal administration of
artesunate and other antimalarial drugs is provided in Section 8.6.

A detailed review of the available data on safety of antimalarials in infants is provided
in Annex 3, Section A3.15.1.

box 7.7

recommendation: treatment for infants and young children with uncomplicated falciparum malaria
 the acutely ill child requires careful clinical monitoring as she/he may deteriorate rapidly.
• ACTs should be used as first-line treatment for infants and young children with uncomplicated malaria,
and careful attention should be paid to accurate dosing and ensuring the administered dose is retained.
• Referral to a health centre or hospital is indicated for young children who cannot swallow antimalarial
medicines reliably. If referral is expected to take more than six hours, pre-referral treatment with rectal
artesunate is indicated.

7.9.4 Large adults

Large adults are a patient group likely to be at risk of under-dosing when dosed by age or
standard pre-packaged adult weight-based treatments, which has received little attention.
As the evidence-base of an association between intake dose, pharmacokinetics and
treatment outcome in overweight or large adults is limited, and the safety of alternative
higher dosing options has not been assessed in treatment trials, these current guidelines
caution treatment providers to be vigilant and follow up the treatment outcome in large
adults where possible. The gap in knowledge needs to be urgently addressed.
7.9.5 Travellers

Travellers who acquire malaria are often non-immune persons either who reside in cities
with little or no transmission within endemic countries, or visitors from non-endemic
countries who travel to areas of malaria transmission. Both are likely to be at a higher
risk for severe malaria. When within the malaria endemic country, they should be treated
according to national policy, provided this has a recent proven cure rate exceeding 90%.
Travellers who return to a non-endemic country and then develop malaria present
particular problems, and they have a relatively high case fatality rate. Doctors in non-
malarious areas may be unfamiliar with malaria, so the diagnosis may be delayed.
Effective antimalarials may not be registered or may be unavailable. On the other hand,
prevention of transmission or the emergence of resistance is irrelevant outside malaria
endemic areas. Thus, monotherapy may be given if it is effective. Furthermore, the cost of
treatment is usually not a limiting factor. The principles underlying the recommendations
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