What is the recommended treatment for an adult patient with uncomplicated malaria?

Management of Malaria in Adults

Uncomplicated Malaria

For uncomplicated Plasmodium falciparum malaria, treat with oral artemisinin-based combination therapy (ACT), specifically artemether-lumefantrine as first-line treatment, which achieves cure rates of 96-100%. 1, 2

First-Line Treatment: Artemether-Lumefantrine (AL)

• Dosing regimen: 4 tablets at hour 0,4 tablets at hour 8 on day 1, then 4 tablets twice daily on days 2 and 3 3, 1, 2
• Critical administration requirement: Must be taken with fatty food or drink to ensure adequate absorption and therapeutic drug levels 1, 4
• Failure to take AL with fatty food is the most common cause of treatment failure 4

Alternative ACT Options

• Dihydroartemisinin-piperaquine (DP): 3 tablets daily for 3 days (36-75 kg) or 4 tablets daily (>75 kg), taken on an empty stomach 2
• Atovaquone-proguanil: 4 tablets daily for 3 days (>40 kg) with fatty meal, reserved for patients with contraindications to ACTs 4, 2

Species-Specific Treatment

For P. vivax, P. ovale, and P. malariae in chloroquine-sensitive regions:

• Chloroquine remains first-line: 1000 mg salt initially, then 500 mg at 6,24, and 48 hours (total 2500 mg over 3 days) 4, 2
• Mandatory follow-up for P. vivax and P. ovale: Primaquine 30 mg base daily for 14 days to eliminate liver hypnozoites and prevent relapse 3, 1, 4
• G6PD testing is mandatory before primaquine administration to prevent life-threatening hemolytic anemia 1, 4

Monitoring for Uncomplicated Malaria

• Check parasitemia every 12 hours until decline to <1%, then every 24 hours until negative 3
• Monitor for post-artemisinin delayed hemolysis (PADH) on days 7,14,21, and 28 after treatment, which occurs in 37.4% of patients 4, 2
• Daily monitoring of complete blood count, hepatic, renal, and metabolic parameters (glucose, blood gas) 3

---

Severe Malaria

For severe P. falciparum malaria (defined by altered consciousness, seizures, shock, pulmonary edema, acidosis, hypoglycemia, high parasitemia >5%, renal impairment, or significant bleeding), admit to intensive care and initiate intravenous artesunate immediately. 3, 1, 5

Intravenous Artesunate Protocol

• First-line treatment for severe malaria with demonstrated mortality reduction compared to quinine 1, 2
• Administer at least 3 doses of IV artesunate 3
• Transition to oral ACT when patient improves clinically (parasitemia <1%) and can tolerate oral medications 3, 2
• Complete a full course of oral ACT following IV artesunate 3, 2

Critical Monitoring in Severe Disease

• Parasitemia every 12 hours until <1%, then every 24 hours until negative 3, 1
• Daily complete blood count, hepatic, renal, and metabolic parameters 3
• Immediate intervention for seizures, hypoglycemia, acidosis, fluid/electrolyte disturbances, renal failure, and secondary infections 6
• Monitor for delayed hemolysis on days 7,14,21, and 28 3, 4

---

Special Populations

Pregnancy

• Artemether-lumefantrine can be used safely in all trimesters of pregnancy with cure rates of 94.9-100% and no increased risk of adverse pregnancy outcomes 1, 4, 2
• Primaquine and tafenoquine are absolutely contraindicated in pregnancy due to hemolysis risk 1, 4

Renal Impairment

• For severe chronic renal impairment: one loading dose of 648 mg quinine sulfate followed 12 hours later by maintenance doses of 324 mg every 12 hours 7
• No dose adjustment required for mild-moderate renal impairment, but close monitoring needed 7

---

Critical Pitfalls to Avoid

• Delayed diagnosis is responsible for preventable deaths annually - evaluate all febrile travelers from endemic regions immediately 3, 5
• Not ensuring fatty food intake with artemether-lumefantrine leads to subtherapeutic drug levels and treatment failure 4, 2
• Failing to test for G6PD deficiency before primaquine can cause life-threatening hemolysis, particularly in Asian populations 1, 4
• Both AL and DP cause QTc prolongation - avoid in patients with baseline QT prolongation or those taking QT-prolonging medications 4, 2
• 71.7% of US residents diagnosed with malaria had not taken chemoprophylaxis during travel - emphasize prevention 5