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ANNEX 8. Treatment of severe Plasmodium falciparum malaria

sequelae (1/18 (6%) with a high initial dose, 2/21 (10%) with no loading dose, RR 0.58,
95% CI 0.06–5.91) (4).

a8.3 Question:
Is intramuscular quinine as effective as intravenous quinine?

summary
One RCT in children found no significant difference between IM and IV quinine in
recovery times or death. However, the study may have lacked the power to detect clinically
important differences between treatments.

Benefits
No systematic review. One RCT (59 children aged < 12 years, Kenya, 1989–1990), which
compared IM quinine (20 mg salt/kg loading immediately followed by 10 mg salt/kg every
12 h) and with standard-dose quinine given by IV infusion (10 mg salt/kg every 12 h)
in severe falciparum malaria (4). The trial found no significant difference in mortality,
mean parasite clearance time or recovery time to drinking or walking, but may have
lacked the power to detect a clinically important difference (mortality: 3/20 (15%) deaths
with IM quinine, 1/18 (5.6%), with IV quinine, RR 2.7, 95% CI 0.3–23.7; mean parasite
clearance time: 57 h compared with 58 h, WMD −1.0 h, 95% CI −12.2 h to +10.2 h; mean
recovery times to drinking 47 h compared with 32 h, WMD +15 h, 95% CI −5.6 h to
+35.6 h; mean recovery times to walking 98 h compared with 96 h, WMD +2.0 h, 95%
CI −24.5 h to +28.5 h).

Harms

Neurological sequelae were reported in two children in the IM group, and one child
in the IV group had transient neurological sequelae that were not specified 2/20 (10%) A8
compared with 1/18 (5.6%), RR 1.8, 95% CI 0.2–18.2 (4).

a8.4 Question:
Is intramuscular artemether as effective as intravenous quinine?

summary

Two systematic reviews and three subsequent RCTs found no significant difference in
death rates between the groups receiving artemether and quinine for severe malaria.

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