Regimens for the Treatment of Malariaa
| Type of Disease or Treatment | Regimen(s) |
|---|---|
| Uncomplicated Malaria | |
| Known chloroquine-sensitive strains of Plasmodium vivax, P. malariae, P. ovale, P. knowlesi, P. falciparumb | Chloroquine (10 mg of base/kg stat followed by 5 mg/kg at 12, 24, and 36 h or by 10 mg/kg at 24 h and 5 mg/kg at 48 h) or Amodiaquine (10-12 mg of base/kg qd for 3 days) |
| Radical treatment for P. vivax or P. ovale infection | In addition to chloroquine or amodiaquine as detailed above, primaquine (0.5 mg of base/kg qd in tropical regions and 0.25 mg/kg for temperate-origin P. vivax) should be given for 14 days to prevent relapse. In mild G6PD deficiency, 0.75 mg of base/kg should be given once weekly for 8 weeks. Primaquine should not be given in severe G6PD deficiency. |
| Sensitive P. falciparum malariac | Artesunated (4 mg/kg qd for 3 days) plus sulfadoxine (25 mg/kg)/pyrimethamine (1.25 mg/kg) as a single dose or Artesunated (4 mg/kg qd for 3 days) plus amodiaquine (10 mg of base/kg qd for 3 days)e |
| Multidrug-resistant P. falciparum malaria | Either artemether-lumefantrined (1.5/9 mg/kg bid for 3 days with food) or Artesunated (4 mg/kg qd for 3 days) plus mefloquine (24-25 mg of base/kg—either 8 mg/kg qd for 3 days or 15 mg/kg on day 2 and then 10 mg/kg on day 3)e or Dihydroartemisinin-piperaquined (2.5/20 mg/kg qd for 3 days) |
| Second-line treatment/treatment of imported malaria | Either artesunated (2 mg/kg qd for 7 days) or quinine (10 mg of salt/kg tid for 7 days) plus 1 of the following 3: 1. Tetracyclinef (4 mg/kg qid for 7 days) 2. Doxycyclinef (3 mg/kg qd for 7 days) 3. Clindamycin (10 mg/kg bid for 7 days) or Atovaquone-proguanil (20/8 mg/kg qd for 3 days with food) |
| Severe Falciparum Malariag | |
Artesunated (2.4 mg/kg stat IV followed by 2.4 mg/kg at 12 and 24 h and then daily if necessary)h or, if unavailable, Artemetherd (3.2 mg/kg stat IM followed by 1.6 mg/kg qd) or, if unavailable, Quinine dihydrochloride (20 mg of salt/kgi infused over 4 h, followed by 10 mg of salt/kg infused over 2-8 h q8hj) or, if unavailable, Quinidine (10 mg of base/kgi infused over 1-2 h, followed by 1.2 mg of base/kg per hourj with electrocardiographic monitoring) | |
aIn endemic areas, except in pregnant women and infants, a single dose of primaquine (0.25 mg of base/kg) should be added as a gametocytocide to all falciparum malaria treatments to prevent transmission. This addition is considered safe even in G6PD deficiency.
bVery few areas now have chloroquine-sensitive P. falciparum malaria (Fig. 248-2 in HPIM-19).
cIn areas where the partner drug to artesunate is known to be effective.
dArtemisinin derivatives are not readily available in some temperate countries.
eFixed-dose coformulated combinations are available. The World Health Organization now recommends artemisinin combination regimens as first-line therapy for falciparum malaria in all tropical countries and advocates use of fixed-dose combinations.
fTetracycline and doxycycline should not be given to pregnant women or to children <8 years of age.
gOral treatment should be substituted as soon as the pt recovers sufficiently to take fluids by mouth.
hArtesunate is the drug of choice when available. The doses in children weighing <20 kg should be 3 mg/kg. The data from large studies in Southeast Asia showed a 35% lower mortality rate than with quinine, and very large studies in Africa showed a 22.5% reduction in mortality rate compared with quinine.
iA loading dose should not be given if therapeutic doses of quinine or quinidine have definitely been administered in the previous 24 h. Some authorities recommend a lower dose of quinidine.
jInfusions can be given in 0.9% saline and 5-10% dextrose in water. Infusion rates for quinine and quinidine should be carefully controlled.