›Avoid in pregnancy and children under 8 years
›QT prolongation monitoring required
›ECG before and during quinine infusion
›Cardiac monitoring mandatory
›IM artemether when IV access unavailable
›3.2 mg/kg IM loading dose
›Then 1.6 mg/kg IM daily
›Less reliable absorption than IV artesunate
›Transition to oral ACT as soon as tolerated
Uncomplicated malaria — chloroquine-resistant or unknown resistance
›Artemether-lumefantrine (Coartem) — first-line
›Adult dosing (>=35 kg)
›4 tablets per dose (each tablet contains 20 mg artemether and 120 mg lumefantrine)
›Twice daily for 3 days — first two doses 8 hours apart
›Must administer with fatty food or full-fat milk to optimize absorption
›Pediatric dosing weight-based
›5 to 14 kg — 1 tablet per dose twice daily times 3 days
›15 to 24 kg — 2 tablets per dose twice daily times 3 days
›25 to 34 kg — 3 tablets per dose twice daily times 3 days
›Evidence and safety
›Class I recommendation for uncomplicated P. falciparum
›Safe in second and third trimester of pregnancy
›Atovaquone-proguanil (Malarone) — alternative
›Adult dosing — 4 adult tablets once daily for 3 days
›Take with food or milky drink
›Contraindicated in pregnancy
›Contraindicated in infants <5 kg
›Avoid in severe renal impairment
›Pediatric dosing by weight
›5 to 8 kg — 2 pediatric tablets daily times 3 days
›9 to 10 kg — 3 pediatric tablets daily times 3 days
›11 to 20 kg — 1 adult tablet daily times 3 days
›Quinine plus doxycycline or tetracycline or clindamycin
›Quinine sulfate 542 mg base (650 mg salt) PO three times daily for 3 or 7 days
›3 days if used with doxycycline or tetracycline
›7 days if used with clindamycin or alone
›Doxycycline 100 mg PO twice daily for 7 days
›Avoid in pregnancy and children under 8
›Clindamycin 20 mg/kg/day PO divided three times daily for 7 days
›Alternative when doxycycline contraindicated
Uncomplicated malaria — chloroquine-sensitive species
›Chloroquine phosphate
›Dosing
›600 mg base (1000 mg salt) initially
›Then 300 mg base (500 mg salt) at 6 hours
›Then 300 mg base at 24 hours and 48 hours
›Total dose 1500 mg base
›Chloroquine-sensitive species
›P. vivax — in most areas except Papua New Guinea and Indonesia
›P. ovale — globally sensitive
›P. malariae — globally sensitive
›P. knowlesi — sensitive
›P. falciparum in Central America (west of Panama Canal), Haiti, Dominican Republic, and Middle East
›Monitoring
›QT prolongation risk — ECG recommended with higher doses
›Retinal toxicity with prolonged use (not an acute concern)
Radical cure — relapse prevention
›Primaquine — P. vivax and P. ovale hypnozoite eradication
›Dosing
›30 mg base once daily for 14 days (standard)
›15 mg base once daily for 14 days (alternative, lower dose)
›G6PD-deficient patients — weekly dosing under expert guidance only
›Mandatory G6PD testing before prescribing
›G6PD deficiency causes severe life-threatening hemolysis
›Contraindicated in pregnancy
›Evidence level
›Class I recommendation for relapse prevention in P. vivax and P. ovale
›Tafenoquine — single-dose alternative
›300 mg single dose for adults >=16 years
›Must be administered with a meal
›G6PD testing mandatory before use
›Contraindicated in G6PD deficiency (any degree)
›Contraindicated in pregnancy and breastfeeding
›Hypoglycemia management
›Point-of-care glucose every 4 hours in severe malaria
›IV dextrose 50% for glucose <2.2 mmol/l
›Quinine and severe infection both cause hypoglycemia
›Fever control
›Acetaminophen (paracetamol) preferred
›1 g PO or IV every 6 hours as needed
›Avoid NSAIDs in dengue overlap concern
›Fluid management
›Judicious IV normal saline for dehydration
›Avoid aggressive bolusing — ARDS and pulmonary edema risk in severe malaria
›Furosemide for pulmonary edema
›40 to 80 mg IV as needed
›Blood transfusion for severe anemia
›Hemoglobin <70 g/L in adults — transfuse packed red cells
›Hemoglobin <50 g/L in children — transfuse
›Exchange transfusion no longer recommended — insufficient evidence