Malaria Author: Rick M. Fairhurst, MD, PhD; Thomas E. Wellems, MD, PhD
Module updated - 2009-11-19
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Prevention
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Drug Therapy
  • Treat uncomplicated P. falciparum malaria according to risk of drug resistance.
  • Know how to obtain and properly administer quinidine to patients with severe malaria who require parenteral treatment.
  • Treat P. vivax, P. ovale, and P. malariae with chloroquine, unless they are acquired in geographic regions where these species are known to be chloroquine resistant.
  • Eradicate persistent liver stages (hypnozoites) of P. vivax and P. ovale with additional drug therapy if there is no contraindication.
Drug Treatment for Malaria (table)

Treat uncomplicated P. falciparum malaria according to risk of drug resistance. A

  • Use oral chloroquine for disease acquired in areas where chloroquine resistance has not been reported (certain Central American countries, Haiti, Dominican Republic, regions of the Middle East).
  • Use oral quinine-doxycycline, mefloquine, atovaquone-proguanil, or artemether-lumefantrine for disease acquired in areas where chloroquine-resistant parasites are present, except for disease acquired along the western and eastern borders of Thailand, where mefloquine should not be used.
  • Use oral quinine-clindamycin instead of quinine-doxycycline in pregnant women and in children under age 8 (due to possible risk of adverse effects on bone development and teeth discoloration) or in patients intolerant of the GI upset associated with doxycycline.
  • Use parenteral quinidine therapy if:
    • The patient develops signs of severe disease
    • The patient cannot tolerate oral therapy
  • Locate and obtain a source of parenteral quinidine should the patient develop signs of severe disease or vomits oral therapy (see information on obtaining and administering quinidine).
  • Seek up-to-date information by contacting the CDC's Malaria Hotline (770-488-7788).
  • Consult a travel clinic specialist in your state who may be helpful in the treatment of malaria, as needed.
  • See table Drug Treatment for Malaria.
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Know how to obtain and properly administer quinidine to patients with severe malaria who require parenteral treatment. A

  • Ensure that hospital drug services maintain quinidine infusion on their formularies or are able to immediately locate a nearby source by contacting local or regional distributors.
  • Arrange a rapid shipment of quinidine in clinical settings, for which the need for quinidine is more acute than can be met by the local or regional distributor, by contacting Eli Lilly and Co. (800-821-0538 from 7:30 a.m. to 6 p.m. EST or 317-276-2000 after hours).
  • Contact the CDC Malaria Hotline (770-488-7788) for advice and assistance in obtaining quinidine, if necessary.
  • Always administer quinidine in an ICU setting.
  • Administer quinidine as 10 mg base/kg (maximum dose 600 mg) infused at a constant rate over 1 to 2 hours, followed by 0.02 mg/kg·min until the patient improves clinically and can complete antimalarial treatment with oral drugs.
  • Never administer quinidine as a bolus injection, which can lead to fatal hypotension.
  • If the patient remains critically ill or is in acute renal failure after 48 hours of quinidine treatment, reduce the infusion rate by 30% to 50% to avoid accumulation of the drug.
  • Maintain quinidine levels at <8 µg/mL, which may require reducing dose by 30% to 50% to prevent drug accumulation in patients who remain seriously ill after 3 days of treatment.
  • Never reduce the initial loading dose of quinidine, even in renal insufficiency.
  • Recognize that quinidine may cause prolongation of the corrected QT interval, thus putting the patient at risk for ventricular tachycardias (e.g., torsade de pointes).
  • If QTc prolongation (>25% of baseline) develops, reduce the infusion rate.
  • Measure serum glucose every 4 to 6 hours and with any acute neurologic change (e.g., diminished consciousness, convulsions), because quinidine may cause hyperinsulinemic hypoglycemia.
  • Administer either 5% or 10% dextrose during quinidine infusion to reduce the incidence of hypoglycemia.
  • Monitor parasite response to quinidine therapy by frequent (every 6 to 8 hours) blood smears to ensure rapid decrease in parasitemia.
  • Administer broad-spectrum antibiotics in addition to quinidine while awaiting blood culture results in patients who present with severe malaria.
  • Stop quinidine once the patient improves and can take oral drugs without vomiting, and complete the antimalarial regimen with:
    • A combination of quinine sulfate tablets (10 mg salt/kg tid) and doxycycline (3 mg/kg·d) to complete a 7-day total course; substitute clindamycin (5 mg/kg tid) if patients cannot take doxycycline
    • Alternatively, a complete 3-day course of atovaquone-proguanil as for uncomplicated malaria
  • See table Drug Treatment for Malaria.
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Treat P. vivax, P. ovale, and P. malariae with chloroquine, unless they are acquired in geographic regions where these species are known to be chloroquine resistant. B

Background | Back to top


Eradicate persistent liver stages (hypnozoites) of P. vivax and P. ovale with additional drug therapy if there is no contraindication. A

  • Use primaquine, the currently available drug for hypnozoite eradication, only in persons without contraindications to its use.
  • Do not administer primaquine to persons with severe forms of G6PD deficiency (e.g., Mediterranean type), to avoid massive and potentially fatal hemolysis.
  • Do not administer primaquine to pregnant women, due to the theoretical risk of hemolytic disease in newborns with G6PD deficiency.
  • After treating P. vivax and P. ovale infections with chloroquine, administer oral primaquine, 0.5 mg base/kg·d (now increased from previous recommendation of 0.25 mg base/kg·d) for 14 days to prevent relapse.
  • Advise patients to take primaquine with food to reduce symptoms of GI side effects.
  • Watch for P. vivax or P. ovale relapses in persons who cannot or do not want to complete a course of primaquine; if these infections occur, clear them with blood-stage antimalarials.
  • Advise patients to discontinue primaquine and seek medical evaluation if their urine becomes dark, because it can cause some degree of hemolysis in persons with mildly deficient or even normal G6PD activity.
  • Do not administer primaquine to persons in endemic areas where reinfection with P. vivax or P. ovale is common.
  • Do not follow-up blood smears to determine treatment effectiveness, because primaquine targets liver stages.
  • See table Drug Treatment for Malaria.
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FAQs
Harry Tagbor, MBChB, DrPH, editorial consultant, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Rick M. Fairhurst, MD, PhD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Thomas E. Wellems, MD, PhD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Steven E. Weinberger, MD, FACP, Acting Editor, PIER, has stock holdings in Glaxosmithkline and Abbott.

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