Malaria - severe
ALWAYS consult Micro/ID about fever in the returning traveller or a diagnosis of malaria. Consider referral to Intensive Care Unit.
Severe malaria includes any case about whom there is a clinical concern. See notes below for specific indications of severity.
Prescribe using the 'Artesunate/Riamet Initiation for Malaria PowerPlan'
Preferred
artesunate 2.4mg/kg iv bd for 3 doses (i.e. at 0h, 12h, 24h) then once a day for 6 days
When the patient is well enough to take orals, switch to oral and complete full 6 dose treatment course of Riamet®. See guideline Malaria - uncomplicated
Alternative
Quinine can be associated with prolonged QT interval. For more information, including MHRA drug safety update, see monographs quinine dihydrochloride and quinine sulfate
- ONLY indicated if artesunate is unavailable OR in the case of hypersensitivity / adverse reaction to artemisinins
- As soon as artesunate injection is available switch iv quinine dihydrochloride to iv artesunate (starting at time 0h).
- Pharmacy will be able to advise about the availability of artesunate injection.
quinine dihydrochloride 20mg/kg iv loading dose then 10mg/kg iv tds for 7 days (doses are for quinine salt)
When the patient is well enough to take orals (See guideline Malaria - uncomplicated), switch to:
- Oral Riamet® and complete full 6 dose treatment course (preferred)
OR
- quinine sulfate 600mg po tds PLUS doxycycline 100mg po bd and complete 7 days
OR
- quinine sulfate 600mg po tds PLUS clindamycin 600mg po bd and complete 7 days
AVOID doxycycline at all stages of pregnancy, see guideline Malaria in Pregnancy
Notes:
Indicators of severe malaria:
- impaired consciousness
- respiratory distress
- seizures
- prostration
- shock
- abnormal bleeding
- jaundice
- severe anaemia
- hypoglycaemia
- acidosis
- renal impairment
- hyperparasitaemia (more than 2%)