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Give proper management of malaria

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WHO Guidelines for malaria 2025 treatment uncomplicated severe malaria artesunate

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https://iris.who.int/server/api/core/bitstreams/26a6af2d-060…

Management of malaria

Management depends on species, severity, pregnancy status, age/weight, G6PD status, and local antimalarial resistance policy. Confirm malaria by peripheral blood smear or a rapid diagnostic test before treatment whenever possible. Do not delay treatment if severe malaria is suspected.

1. Initial assessment

  1. Confirm parasite and identify species if possible.
  2. Assess severity and admit urgently if any danger sign is present:
    • Impaired consciousness, repeated seizures, prostration
    • Respiratory distress/acidosis
    • Shock or bleeding
    • Severe anaemia
    • Hypoglycaemia
    • Jaundice with organ dysfunction
    • Acute kidney injury, oliguria
    • Pulmonary oedema/ARDS
    • Haemoglobinuria
    • Hyperparasitaemia
    • Persistent vomiting or inability to take oral drugs
  3. Obtain baseline tests where available: CBC/haemoglobin, glucose, renal and liver function, parasite density, blood group and cross-match in severe anaemia.
  4. Monitor clinical condition, blood glucose, urine output, haemoglobin and parasite clearance.

2. Uncomplicated malaria

A. Plasmodium falciparum malaria

Treat with a 3-day artemisinin-based combination therapy (ACT) selected according to national/local policy. WHO-approved options include:
  • Artemether-lumefantrine
  • Dihydroartemisinin-piperaquine
  • Artesunate-amodiaquine
  • Artesunate-mefloquine
  • Artesunate-sulfadoxine-pyrimethamine only where the partner drug remains effective
Avoid oral artemisinin monotherapy because it promotes resistance. Current WHO guidance recommends an ACT for uncomplicated P. falciparum malaria in adults and children, including pregnancy in the second and third trimesters. WHO malaria guideline
A single low dose of primaquine may be used as a gametocytocidal drug in certain national programmes, but do not give it in pregnancy, infants, or known G6PD deficiency. Follow the local policy.

B. P. vivax or P. ovale malaria

  1. Blood-stage treatment
    • Use chloroquine only in areas with confirmed chloroquine-sensitive parasites.
    • In areas with resistance or unknown sensitivity, use an appropriate ACT.
  2. Radical cure to prevent relapse
    • Give primaquine for 14 days after confirming normal G6PD activity.
    • Tafenoquine may be an alternative in settings where approved, but also requires quantitative G6PD testing.
Do not give primaquine or tafenoquine in:
  • Pregnancy
  • Infants
  • G6PD deficiency
  • Breastfeeding when the infant’s G6PD status is unknown or deficient
In pregnancy, treat acute vivax malaria with chloroquine where susceptible; defer radical cure until after delivery. Park notes chloroquine for susceptible vivax disease and a 14-day primaquine course for relapse prevention, with primaquine contraindicated in G6PD deficiency and pregnancy. Park's Textbook of Preventive and Social Medicine, pp. 306-307.

C. Mixed infection

Treat as falciparum malaria, with an ACT. Then consider radical cure for the vivax/ovale component only after G6PD assessment and if not contraindicated.

D. P. malariae and P. knowlesi

  • P. malariae: chloroquine where susceptible, or ACT.
  • P. knowlesi: treat with an ACT; manage as severe malaria if any severe features are present because deterioration may be rapid.

3. Severe or complicated malaria

This is a medical emergency. Admit to hospital, preferably ICU/high-dependency care.

Specific antimalarial treatment

IV artesunate is first-line.
  • Adults and children ≥20 kg: 2.4 mg/kg IV or IM at 0, 12, and 24 hours, then once daily
  • Children <20 kg: 3 mg/kg per dose at the same schedule
Continue parenteral artesunate for at least 24 hours and until the patient can take oral treatment. Then complete a full 3-day oral ACT. WHO recommends IV or IM artesunate for severe malaria in all age groups and throughout pregnancy. WHO severe-malaria recommendation
If artesunate is unavailable, use IV quinine/quinidine according to local protocol, with ECG and glucose monitoring. IV artesunate is superior to quinine and is the preferred treatment. Goldman-Cecil Medicine, p. 2416.

Supportive management

  • Airway and breathing: oxygen, protect airway, intubate/ventilate if coma, aspiration risk, or respiratory failure.
  • Fluids: cautious isotonic fluid replacement. Avoid fluid overload because pulmonary oedema may occur.
  • Hypoglycaemia: check glucose repeatedly and correct promptly with IV dextrose.
  • Seizures: maintain airway and treat promptly with benzodiazepines.
  • Severe anaemia: transfuse packed red blood cells where indicated.
  • Acute kidney injury: strict input-output charting, monitor electrolytes, dialysis if needed.
  • Shock/sepsis: obtain cultures if indicated, give antibiotics if bacterial sepsis cannot be excluded, and use vasopressors when required.
  • Fever: paracetamol and physical cooling.
  • Avoid harmful routine measures: corticosteroids, mannitol, prophylactic anticonvulsants, and routine exchange transfusion are not recommended solely for cerebral malaria.
Monitor for post-artesunate delayed haemolysis after IV artesunate, particularly during the following few weeks.

4. Malaria in pregnancy

  • Test urgently and treat promptly.
  • Severe malaria: IV artesunate in any trimester.
  • Uncomplicated falciparum malaria:
    • First trimester: use the regimen recommended by the local programme, commonly quinine plus clindamycin where ACT is not recommended.
    • Second and third trimesters: ACT is generally recommended.
  • Vivax malaria: chloroquine if locally effective.
  • Primaquine and tafenoquine are contraindicated during pregnancy.

5. Follow-up and prevention

  • Reassess clinically within 24-48 hours and repeat smear/RDT or microscopy according to local practice, especially if symptoms persist.
  • Check adherence and vomiting of oral medication.
  • Investigate treatment failure, reinfection, wrong species identification, or drug resistance if fever/parasitaemia persists.
  • Counsel on insecticide-treated bed nets, repellents, protective clothing, indoor residual spraying where applicable, and travel chemoprophylaxis for endemic-area travel.
  • Notify public-health authorities where malaria is a notifiable disease.
Key rule: uncomplicated malaria needs a complete oral species-appropriate regimen; any severe feature requires immediate parenteral artesunate plus intensive supportive care.

Maximum dosage of artesunate

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artesunate AND severe malaria

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WHO malaria guidelines artesunate maximum dose severe malaria 2.4 mg/kg maximum

For severe malaria, artesunate is dosed by body weight, not as a universal fixed maximum:
  • Adults and children ≥20 kg: 2.4 mg/kg per dose IV or IM
  • Children <20 kg: 3 mg/kg per dose IV or IM
Give at 0, 12, and 24 hours, then once daily until oral medication can be taken. Complete treatment with a full 3-day ACT afterward.
WHO guidance does not specify a maximum mg cap per dose for IV/IM artesunate. Calculate from the patient’s actual body weight. WHO malaria guidance
For pre-referral rectal artesunate in suspected severe malaria: 10 mg/kg rectally as a single dose, then immediately transfer to a facility for definitive injectable treatment.
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