Treatment of Malaria With Quinine Plus Sulfadoxine-Pyrimethamine

One main concern of clinicians in malaria endemic areas is to find a simple malaria treatment with short treatment duration. The concept of combination therapy, which may reduce treatment duration and delay the spread of drug resistance in addition to an increase in efficacy, has been therefore introduced.

In contrast to the outpatient treatment of malaria where emergence of resistance has lead to new drugs policies, the treatment of hospitalised malaria cases remains, in many endemic countries, intravenous quinine for 7 days. The efficacy of this regimen is well established throughout Africa. The effectiveness of the quinine treatment may be considerably lower because of discontinuation of treatment due to early discharge, the occurrence of side effects or because of the fact that patients feel better and stop the treatment. Therefore, sulfadoxine-pyrimethamine (SP) is often added at discharge. This regimen has been shown to be effective. But in Africa, where the practice seems widespread, it has been assessed in only two trials.

Since resistance of Plasmodium falciparum to SP is increasing rapidly in Africa and there is evidence that SP monotherapy induce gametocytaemia, we hypothesize that the combination quinine/SP increases SP efficacy and prevents induction of gametocytaemia. In addition, since the use of the full course of quinine therapy may be hampered by many factors (hospital cost, hospitalisation duration, availability of beds, compliance and side effects), the addition of the long acting SP to complete a short course of quinine treatment may prevent recrudescence or reinfection and may increase effectiveness of malaria treatment and reduce postdischarge morbidity.

The efficacy and safety of the short course of intravenous quinine (3-day treatment) plus a single dose of oral SP for the treatment of falciparum malaria was investigated.

Inclusion criteria

• Uncomplicated falciparum malaria
• Asexual parasitaemia between 20,000 and 200,000/µL
• No mixed plasmodial infection
• Fever with temperature above 38 °C or history of fever during the preceding 24 hours
• No effective anti-malarial treatment for the present attack
• Informed consent

Exclusion criteria

• Haemoglobin < 7 g/dL
• Packed-cell volume < 20%
• White cell count > 16,000/µL
• Platelet count < 40,000/µL
• Schizontaemia > 50/µL
• Impaired consciousness
• Convulsions or history of convulsions
• Concomitant diseases masking assessment of response