[Table of Contents]

Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers
1995

Management of Falciparum Malaria

The following guidelines have been derived from the World Health Organization Division of Control of Tropical Diseases [Severe and complicated malaria, 2nd ed. Trans Roy Soc Trop Med Hyg 1990;84(Suppl 2)(update 1995; in press)]. The interested reader is referred to this document for a more detailed discussion of this subject.

A detailed geographic history is essential to the management of malaria infections. P. falciparum malaria acquired in areas with drug resistance must be considered to be chloroquine-resistant and, therefore, should be treated as such.

Severe P. falciparum infections, as defined by the criteria in Table 3, may have a mortality rate of 30% or higher. These patients require immediate hospitalization, and urgent and intensive medical management. As a general rule, consideration should be given to admit all patients with P. falciparum malaria, whether severe or not, to allow for monitoring of the patient during initiation of therapy. In the treatment of complicated malaria, results following use of parenteral preparations of quinine and quinidine are equivalent. Although equally active, quinidine is more cardiotoxic than quinine and patients treated with intravenous quinidine should be monitored electrocardiographically. Quinidine is licensed and widely distributed in Canada, but intravenous quinine is an emergency release drug and is not readily available. Therefore, to emphasize its availability parenteral quinidine is placed first in the recommendations. However, either drug is acceptable for treatment. Parenteral quinidine is marketed by several drug companies as listed in the Canadian Compendium of Pharmaceuticals and Specialties.

Uncomplicated P. falciparum infections unequivocally acquired in a chloroquine-sensitive zone (Zone A) may be treated with chloroquine alone, as per Table 2. Uncomplicated P. falciparum infections that were possibly or definitely acquired in Zones B or C should be treated with quinine and a second drug, as described in the next paragraph. If the patient can tolerate oral quinine, then it and the second drug should be administered as per Table 2.

All patients with severe P. falciparum infections, and those who are unable to tolerate oral quinine, regardless of the severity of the infection, should receive intravenous quinidine or quinine. At this time, parenteral quinine is an emergency drug that can be obtained through the Emergency Drug Release Program, Health Canada, telephone 613-993-3105. Parenteral quinidine, which is equally effective in the treatment of malaria, is available in most hospital pharmacies. The recommended dosing schedule is given in Table 4. For drug-resistant P. falciparum malaria, another agent, in addition to quinine or quinidine, is recommended. The second drug - either doxycycline, Fansidar®, or clindamycin - may be administered simultaneously or sequentially, either orally (as per Table 2) or, if not possible, then parenterally (as per Table 4). The base-salt equivalents of selected antimalarials are shown in Table 5.

When quinine is administered to a patient who has taken mefloquine during the last 2 weeks, there is a risk of drug-induced cardiac arrhythmia; if possible, such patients should be monitored electrocardiographically.

In cases of complicated P. falciparum infection (Table 3), or hyperparasitemia (> 5% in non-immune individuals), exchange transfusion has been used on an experimental basis as a potentially life-saving procedure. If this situation arises, consultation with a hematologist and an expert in tropical diseases is strongly recommended.

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