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
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Artemether-lumefantrine (ACT)[2] | Artemisinin-based combination therapy | 80/480 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 days | First-line uncomplicated P. falciparum; not in first trimester pregnancy |
| Artesunate-pyronaridine (alternative ACT)[2] | Artemisinin-based combination | Weight-based for 3 days | Weight-band tablets | Alternative ACT in areas with reduced lumefantrine efficacy; once-daily dosing improves adherence |
| Chloroquine + primaquine (P. vivax/ovale)[2] | Aminoquinoline antimalarials | 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) | 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) | 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 dose | Severe malaria (any species); reduces mortality 35% vs quinine in adults, 22% in children |
| Quinine + clindamycin (first-trimester pregnancy)[2] | Cinchona alkaloid + lincosamide | Quinine 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
- Complete the full course of antimalarial including the radical cure for vivax/ovale (primaquine 14 days) — incomplete treatment causes relapse[2]
- Returned traveller with fever — seek medical care urgently and mention travel history; malaria can be rapidly fatal[2]
- 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).