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8. Treatment of severe P. falciparum malaria

body weight) is administered at 8-h intervals, starting 8 h after the first dose (see Annex
9, Section A9.3.2).

Rapid administration of quinine is unsafe. Each dose of parenteral quinine must be
administered as a slow, rate-controlled infusion (usually diluted in 5% dextrose and infused
over 4 h). The infusion rate should not exceed 5 mg salt/kg body weight per hour.

8.4.3 Quinidine

Quinidine commonly causes hypotension and concentration-dependent prolongation of
ventricular repolarization (QT prolongation). Quinidine is thus considered more toxic
than quinine and should only be used if no other effective parenteral drugs are available.
Electrocardiographic monitoring and frequent assessment of vital signs are required if
quinidine is used.r

8.5 Follow-on treatment

Following initial parenteral treatment, once the patient can tolerate oral therapy, it is
essential to continue and complete treatment with an effective oral antimalarial using
a full course of an effective ACT (artesunate plus amodiaquine or artemether plus
lumefantrine or dihydroartemisinin plus piperaquine) or artesunate (plus clindamycin or
doxycycline) or quinine (plus clindamycin or doxycycline). Doxycycline is preferred to other
tetracyclines because it can be given once daily, and does not accumulate in renal failure.
But as treatment with doxycycline only starts when the patient has recovered sufficiently,
the 7-day doxycycline course finishes after the quinine, artemether or artesunate course.
Where available, clindamycin may be substituted in children and pregnant women;
doxycycline cannot be given to these groups. Regimens containing mefloquine should
be avoided, if the patient presented initially with impaired consciousness. This is because
of an increased incidence of neuropsychiatric complications associated with mefloquine
following cerebral malaria.

The current recommendation from experts’ opinion is to give parenteral antimalarials in
the treatment of severe malaria for a minimum of 24 h, once started (irrespective of the
patient’s ability to tolerate oral medication earlier) or until the patient is about to tolerate
oral medication, before giving the oral follow-up treatment.

8.6 Pre-referral treatment options
The risk of death from severe malaria is greatest in the first 24 h, yet, in most malaria
endemic countries, the transit time between referral and arrival at health facilities able to
administer intravenous treatment is usually prolonged; this delays the commencement of
appropriate antimalarial treatment. As during this time the patient may deteriorate or die,
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