COMPARISON OF ARTEMISININ SUPPOSITORIES, INTRAMUSCULAR ARTESUNATE ANDINTRAVENOUS QUININE FOR THE TREATMENT OF SEVERE CHILDHOOD MALARIA

Severe malaria remains a major cause of mortality and morbidity for ch ildren living in many tropical regions. With the emergence of strains of Plasmodium falciparum resistant to both chloroquine and quinine, al ternative antimalarial agents are required. The artemisinin group of c ompounds are rapidly effective in severe disease when given by intramu scular or intravenous injection. However, these routes of administrati on are not always available in rural areas. In an open, randomized com parison 109 Vietnamese children, aged between 3 months and 14 years, w ith severe P. falciparum malaria, were allocated at random to receive artemisinin suppositories followed by mefloquine (n = 37), intramuscul ar artesunate followed by mefloquine (n = 37), or intravenous quinine followed by pyrimethamine/sulfadoxine (n = 35). There were 9 deaths: 2 artemisinin, 4 artesunate and 5 quinine-treated children. There was n o difference in fever clearance time, coma recovery, or length of hosp ital stay among the 3 groups. However, parasite clearance times were s ignificantly faster in artemisinin and artesunate-treated patients tha n in those who received quinine (P < 0.0001). Both artemisinin and art esunate were very well tolerated, but children receiving these drugs h ad lower peripheral reticulocyte counts by day 5 of treatment than tho se in the quinine group (P = 0.011). No other adverse effect or toxici ty was found. There was no treatment failure in these 2 groups, but 4 patients in the quinine group failed to clear their parasites within 7 d of starting treatment and required alternative antimalarial therapy . Artemisinin suppositories are easy to administer, cheap, and very ef fective for treating children with severe malaria. In rural areas wher e medical facilities are lacking these drugs will allow antimalarial t herapy to be instituted earlier in the course of the disease and may t herefore save lives.