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Infectious Disease · ICMR

Malaria treatment

ICMR
A
Source:ICMR / National Vector Borne Disease Control Programme — National Drug Policy on Malaria (2021)WHO Guidelines for Malaria 2024
Verified Apr 2026
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Red Flags

  • Severe malaria (impaired consciousness, jaundice, hypoglycaemia, AKI, anaemia, shock, hyperparasitemia >10%, respiratory distress) — IV artesunate within 1 hour[2]
  • Pregnancy with falciparum malaria — first trimester quinine + clindamycin; second/third trimester ACT (artemether-lumefantrine); severe disease IV artesunate any trimester[2]
  • Cerebral malaria (impaired consciousness with falciparum) — ICU; IV artesunate plus glucose monitoring (hypoglycaemia common)[2]
  • Vivax relapse after primaquine — confirm G6PD status; consider tafenoquine alternative (single dose), or extended primaquine course[2]

First-line treatment

Interventions

  • Severe malaria supportive care[2]
    ICU; manage hypoglycaemia, AKI, ARDS, DIC, secondary bacterial infection. Avoid over-hydration (pulmonary oedema)

First-line drug therapy

DrugClassAdultPaediatricNotes
Artemether-lumefantrine (ACT)[2]Artemisinin-based combination therapy80/480 mg PO BD × 3 days (with fat-containing food)Weight-band: 5–14 kg: 1 tab; 15–24 kg: 2 tabs; 25–34 kg: 3 tabs; ≥35 kg: 4 tabs BD × 3 daysFirst-line uncomplicated P. falciparum; not in first trimester pregnancy
Artesunate-pyronaridine (alternative ACT)[2]Artemisinin-based combinationWeight-based for 3 daysWeight-band tabletsAlternative ACT in areas with reduced lumefantrine efficacy; once-daily dosing improves adherence
Chloroquine + primaquine (P. vivax/ovale)[2]Aminoquinoline antimalarialsChloroquine 25 mg base/kg over 3 days + primaquine 0.25–0.5 mg/kg/day × 14 days (G6PD-normal); 0.75 mg/kg weekly × 8 weeks (mild G6PD deficiency)Same per kgVivax/ovale radical cure; primaquine eliminates hypnozoites; tafenoquine 300 mg single dose alternative in G6PD-normal adults
IV artesunate[2]Artemisinin (parenteral)2.4 mg/kg IV at 0, 12, 24 h then daily; switch to oral ACT once tolerating after at least 24 h IV<20 kg: 3 mg/kg per dose; ≥20 kg: 2.4 mg/kg per doseSevere malaria (any species); reduces mortality 35% vs quinine in adults, 22% in children
Quinine + clindamycin (first-trimester pregnancy)[2]Cinchona alkaloid + lincosamideQuinine 600 mg PO TID × 7 days plus clindamycin 450 mg PO TID × 7 days—Pregnancy first trimester with uncomplicated falciparum where ACT contraindicated
Artemether-lumefantrine (ACT)[2]
Artemisinin-based combination therapy
Adult
80/480 mg PO BD × 3 days (with fat-containing food)
Paediatric
Weight-band: 5–14 kg: 1 tab; 15–24 kg: 2 tabs; 25–34 kg: 3 tabs; ≥35 kg: 4 tabs BD × 3 days
First-line uncomplicated P. falciparum; not in first trimester pregnancy
Artesunate-pyronaridine (alternative ACT)[2]
Artemisinin-based combination
Adult
Weight-based for 3 days
Paediatric
Weight-band tablets
Alternative ACT in areas with reduced lumefantrine efficacy; once-daily dosing improves adherence
Chloroquine + primaquine (P. vivax/ovale)[2]
Aminoquinoline antimalarials
Adult
Chloroquine 25 mg base/kg over 3 days + primaquine 0.25–0.5 mg/kg/day × 14 days (G6PD-normal); 0.75 mg/kg weekly × 8 weeks (mild G6PD deficiency)
Paediatric
Same per kg
Vivax/ovale radical cure; primaquine eliminates hypnozoites; tafenoquine 300 mg single dose alternative in G6PD-normal adults
IV artesunate[2]
Artemisinin (parenteral)
Adult
2.4 mg/kg IV at 0, 12, 24 h then daily; switch to oral ACT once tolerating after at least 24 h IV
Paediatric
<20 kg: 3 mg/kg per dose; ≥20 kg: 2.4 mg/kg per dose
Severe malaria (any species); reduces mortality 35% vs quinine in adults, 22% in children
Quinine + clindamycin (first-trimester pregnancy)[2]
Cinchona alkaloid + lincosamide
Adult
Quinine 600 mg PO TID × 7 days plus clindamycin 450 mg PO TID × 7 days
Paediatric
—
Pregnancy first trimester with uncomplicated falciparum where ACT contraindicated

Safety-net

  1. Complete the full course of antimalarial including the radical cure for vivax/ovale (primaquine 14 days) — incomplete treatment causes relapse[2]
  2. Returned traveller with fever — seek medical care urgently and mention travel history; malaria can be rapidly fatal[2]
  3. If you have G6PD deficiency, take only the regimen prescribed for you — primaquine and tafenoquine cause severe haemolysis[2]

Referral criteria

  • Severe malaria (any species)Hospital admission for IV artesunate; ICU/HDU consideration[2]
  • Pregnancy with malariaJoint obstetric and ID care[2]
  • Treatment failure (parasitaemia persisting beyond 72 h)Infectious diseases for resistance evaluation; switch to alternative ACT[2]
  • Vivax relapse despite primaquineID for G6PD review and tafenoquine consideration[2]

Clinical summary

Species-specific treatment of uncomplicated and severe malaria; ACT for falciparum, chloroquine + primaquine for vivax (G6PD-screened).

References

  1. 1.ICMR / National Vector Borne Disease Control Programme — National Drug Policy on Malaria; WHO Guidelines for Malaria 2024 (2021)
  2. 2.National Drug Policy on Malaria; WHO Guidelines for the treatment of malaria 2024. NVBDCP / ICMR / WHO (2024)

On this page

  • Red flags
  • First-line treatment
  • Safety-net
  • Referral
  • References