| TYPE OF DISEASE OR TREATMENT | REGIMEN(S) |
|---|---|
| Uncomplicated malaria | |
| Known chloroquine-sensitive strains of Plasmodium vivax, P. malariae, P. ovale, 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 earlier or ACT as detailed next, primaquine (0.5 mg of base/kg qd in Southeast Asia and Oceania and 0.25 mg/kg elsewhere) 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. |
| 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 or 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 DHA-piperaquined (target dose: 4/24 mg/kg qd for 3 days in children weighing <25 kg and 4/18 mg/kg qd for 3 days in persons weighing ≥25 kg) |
| Second-line treatment/treatment of imported malaria | 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,h | |
Artesunated (2.4 mg/kg stat IV followed by 2.4 mg/kg at 12 and 24 h and then daily if necessary; for children weighing <20 kg, give 3 mg/kg per dose)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 none of the above are available, Quinidine (10 mg of base/kgi infused over 1-2 h, followed by 1.2 mg of base/kg per hour j with electrocardiographic monitoring) | |
a In endemic areas where malaria transmission is low, 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.
b Very few areas now have chloroquine-sensitive P. falciparum malaria.
c In areas where the partner drug to artesunate is known to be effective.
dArtemisinin derivatives are not readily available in some temperate countries.
e Fixed-dose co-formulated 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.
f Tetracycline and doxycycline should not be given to pregnant women after 15 weeks of gestation or to children <8 years of age.
g Oral treatment should be substituted as soon as the pt recovers sufficiently to take fluids by mouth.
h Artesunate is the drug of choice when available. 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. The doses of artesunate in children weighing <20 kg should be 3 mg/kg.
i A 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.
j Infusions can be given in 0.9% saline and 5-10% dextrose in water. Infusion rates for quinine and quinidine should be carefully controlled.
Abbreviations: ACT, artemisinin combination therapy; DHA, dihydroartemisinin; G6PD, glucose-6-phosphate dehydrogenase.