31 August 2026Chapter 6: Parasitic diseasesPDF page 181
Malaria
Comprehensive clinical guide to malaria diagnosis, severe disease recognition, antimalarial treatment, complications, pregnancy care, and prevention.
This guide supports clinical education and care navigation. It does not replace bedside judgement, emergency care, specialist advice, or local treatment protocol.
Seek urgent care
- Confusion, unusual sleepiness, coma, repeated seizures, or extreme weakness.
- Fast or laboured breathing, shock signs, jaundice, abnormal bleeding, or very dark urine.
- Any suspected malaria in pregnancy, young infants, or a person unable to drink.
Definition and epidemiology
Malaria is infection with Plasmodium parasites transmitted mainly by Anopheles mosquitoes. P. falciparum causes most severe and fatal malaria, but other species may cause relapsing or persistent disease.
In endemic areas, or after travel to endemic areas, fever or recent fever should prompt malaria testing while other causes of fever are still considered. A positive test does not automatically explain every fever, and co-infection is common.
Young children, pregnant patients, malnourished patients, and non-immune travellers can deteriorate quickly and need lower thresholds for reassessment, referral, and parenteral treatment.
Clinical features
- Uncomplicated malaria commonly presents with fever or recent fever, chills, sweating, headache, malaise, muscle pains, anorexia, nausea, vomiting, or diarrhoea.
- Children may present with abdominal pain, diarrhoea, vomiting, pallor, splenomegaly, or clinical anaemia rather than a classic fever pattern.
- Severe malaria may present with impaired consciousness, coma, repeated convulsions, prostration, inability to drink or breastfeed, respiratory distress, shock, jaundice, abnormal bleeding, haemoglobinuria with dark red urine, severe anaemia, hypoglycaemia, acidosis, or acute renal failure.
- Reduced urine output is concerning: children with oliguria below 12 ml/kg/day or adults below about 400 ml/day despite hydration need urgent assessment for renal failure.
Laboratory confirmation
- Confirm malaria whenever testing is available. Rapid diagnostic tests are useful at primary-care level but are qualitative and may remain positive after parasites have cleared.
- Microscopy with thick and thin films can identify parasite species, estimate density, and monitor response when skilled microscopy is available.
- A negative blood film does not fully exclude severe malaria because infected red cells may be sequestered away from peripheral blood, especially in falciparum disease.
- Measure haemoglobin in patients with pallor or clinical anaemia and in all severe malaria. Measure blood glucose in severe malaria and in malnourished patients because hypoglycaemia can be rapidly fatal.
- Assess hydration, urine output, respiratory pattern, jaundice, bleeding, pregnancy status, weight, age, ability to tolerate oral medicine, and alternative fever sources before finalising the plan.
Uncomplicated malaria treatment
Treatment depends on species, local resistance, pregnancy status, drug availability, age, weight, and severity. Use the national first-line artemisinin-based combination therapy (ACT) where available and clinically appropriate.
- Quinine PO is no longer standard first-line treatment in many protocols, but where it is used: patients under 50 kg receive 10 mg/kg three times daily for 7 days; adults 50 kg and over receive 600 mg three times daily for 7 days.
- Infants and small children below fixed-dose ACT table weights require dose calculation from target mg/kg ranges and close follow-up because deterioration can be rapid.
| Medicine | Dose |
|---|---|
| Chloroquine base | Day 1: 10 mg/kg PO; Day 2: 10 mg/kg PO; Day 3: 5 mg/kg PO. Use ACT instead where chloroquine resistance is significant or chloroquine is not recommended. |
| Primaquine for P. vivax or P. ovale relapse prevention | Children 15 kg and over: 0.25 to 0.5 mg/kg PO once daily for 14 days. Adults: 15 mg PO once daily for 14 days. Use only after G6PD risk assessment and avoid in G6PD deficiency. |
| Situation | Treatment principle |
|---|---|
| Uncomplicated falciparum malaria | Treat with a locally recommended ACT for 3 days, such as artemether-lumefantrine, artesunate-amodiaquine, or dihydroartemisinin-piperaquine. |
| Low-transmission or elimination settings | A single low dose of primaquine may be added for transmission reduction when local policy recommends it; avoid in pregnancy, breastfeeding of infants under 6 months, and children under 30 kg where contraindicated by protocol. |
| Vomiting after oral antimalarial | If vomiting occurs within 30 minutes, repeat the full dose; if within 30 to 60 minutes, repeat half the dose. Persistent vomiting should be treated as inability to tolerate oral therapy and may require severe-malaria management. |
Severe malaria and pre-referral care
Severe malaria is a medical emergency. Do not delay antimalarial treatment while arranging transfer. Give glucose or sugar before and during transfer if the patient is drowsy, unable to feed, convulsing, severely ill, or at risk of hypoglycaemia.
- Severe signs include coma or impaired consciousness, more than two seizures in 24 hours, prostration, inability to sit, drink, suck, or breastfeed, respiratory distress, shock, jaundice, haemoglobinuria, abnormal bleeding, severe anaemia, hypoglycaemia, acidosis, and renal failure.
- Hospitalise all severe malaria. Manage airway, breathing, circulation, glucose, seizures, hydration, urine output, temperature, anaemia, infection differential diagnosis, and complications in parallel.
| Setting | Treatment |
|---|---|
| Community level, child under 6 years when injection is unavailable | Rectal artesunate 10 mg/kg once before transfer. Practical bands: 2 months to under 3 years and up to 10 kg: 100 mg; 3 to under 6 years and up to 20 kg: 200 mg. |
| Dispensary or facility able to inject | Give the first dose of parenteral artesunate; if unavailable, use artemether according to protocol, then transfer urgently. |
Parenteral severe malaria treatment
- Use IV artesunate rather than IM in shock when possible.
- Once the patient can swallow, always complete treatment with a full effective oral ACT rather than stopping after parenteral improvement.
- Monitor for haemolysis, recurrent fever, persistent parasitaemia, vomiting, hypoglycaemia, worsening consciousness, respiratory distress, renal impairment, and fluid overload.
| Weight group | Dose schedule |
|---|---|
| Under 20 kg | 3 mg/kg per dose at hour 0, hour 12, and hour 24, then once daily. |
| 20 kg and over, including adults | 2.4 mg/kg per dose at hour 0, hour 12, and hour 24, then once daily. |
| Minimum duration | Give at least 24 hours and at least 3 doses, then complete a full 3-day ACT when oral treatment is tolerated. If oral treatment is not possible, continue daily parenteral treatment up to 7 days. |
| Medicine | Dose schedule |
|---|---|
| Artemether IM only | 3.2 mg/kg on day 1, then 1.6 mg/kg once daily. Give at least 24 hours and 2 doses before switching to oral ACT when possible. |
| Quinine IV | Use only where needed and monitor closely. A loading dose may be used unless quinine or mefloquine was taken in the previous 24 hours; then continue maintenance dosing every 8 hours according to protocol with glucose-containing fluid. |
Supportive management and complications
- Hydration: correct dehydration carefully, but avoid fluid overload. Pulmonary oedema can occur, especially with renal impairment or aggressive fluids.
- Fever: use paracetamol for high fever or discomfort and avoid unnecessary antipyretic escalation.
- Severe anaemia: measure haemoglobin and manage according to the anaemia pathway, including transfusion when indicated.
- Hypoglycaemia: check glucose early and repeatedly in severe malaria, pregnancy, malnutrition, quinine treatment, altered consciousness, or seizures; treat immediately with glucose or emergency sugar when needed.
- Coma: protect airway, place in recovery position, check glucose, monitor level of consciousness, catheterise if needed, monitor vital signs and fluid balance closely, and consider meningitis or sepsis when the presentation is not fully explained.
- Convulsions: treat using the seizures pathway and keep checking glucose and temperature.
- Respiratory distress: distinguish pulmonary oedema from deep acidotic breathing. For pulmonary oedema, reduce IV fluid, sit the patient upright, give oxygen, and consider furosemide 1 mg/kg IV in children or 40 mg IV in adults, repeating after 1 to 2 hours if necessary.
- Renal failure: monitor urine output, avoid nephrotoxins, restrict fluids when oliguria persists, and arrange dialysis where available for established acute renal failure.
Pregnancy, prevention, and follow-up
- In pregnancy, treat non-falciparum malaria as usual but do not give primaquine. ACT can be used for uncomplicated falciparum malaria in all trimesters; if ACT is unavailable, quinine plus clindamycin may be used according to protocol.
- Severe malaria in pregnancy is treated with artesunate in all trimesters; artemether is an alternative when artesunate is unavailable. Quinine IV is not preferred when artemisinin derivatives are available.
- Prevention includes prompt testing and treatment of fever, long-lasting insecticide-treated nets in inpatient and endemic settings, vector control, mosquito avoidance, and travel prevention advice.
- Seasonal malaria chemoprevention may be used in Sahel and similar seasonal-transmission settings for children under 5 years, commonly with monthly amodiaquine plus sulfadoxine-pyrimethamine during the transmission season according to national policy.
- Handover should include species or test result, severity signs, pregnancy status, weight, antimalarial doses and times, glucose and haemoglobin results, urine output, complications, fluids, seizures, antibiotics if given, and completion ACT plan.
Medicines in this guide
Artemether-lumefantrine oralArtemisinin-based combination therapy option for uncomplicated falciparum malaria.Artesunate-amodiaquine oralArtemisinin-based combination therapy option where locally recommended.Dihydroartemisinin-piperaquine oralArtemisinin-based combination therapy option where locally recommended.Artesunate injectablePreferred parenteral treatment for severe malaria, including pregnancy.Artesunate rectalPre-referral treatment for young children when parenteral treatment is not immediately available.Artemether injectableAlternative parenteral severe-malaria treatment when artesunate is unavailable.Quinine injectableAlternative severe-malaria treatment only where first-line parenteral artemisinin therapy is unavailable.Quinine oralAlternative regimen in selected protocols or pregnancy contexts when ACT is unavailable.Chloroquine oralTreatment option for susceptible non-falciparum malaria.Primaquine oralUsed for vivax or ovale relapse prevention after G6PD risk assessment.Clindamycin oralPartner medicine with quinine in pregnancy when ACT is unavailable.Amodiaquine oralUsed with sulfadoxine-pyrimethamine for seasonal malaria chemoprevention in selected settings.Sulfadoxine-pyrimethamine oralUsed with amodiaquine for seasonal malaria chemoprevention where recommended.Furosemide injectableUsed in fluid overload or pulmonary oedema during severe-malaria supportive care.
Source
MSF Clinical guidelines - Diagnosis and treatment manual (December 2024)
This page is a paraphrased clinician-oriented guide derived from the source topic on PDF page 181. Medicine-specific details should be checked against local protocol and the linked drug-information pages.