Intravenous artesunate versus intravenous quinine in the treatment of severe falciparum malaria: a retrospective evaluation from a UK centre

Abstract

Introduction: Despite evidence from developing world trials that intravenous (IV) artesunate (AS) is superior to IV quinine (Q) in severe falciparum malaria (FM), IV AS remains unlicensed in the UK with national guidelines listing it as an acceptable alternative to IV Q as the drug of choice. We retrospectively evaluate the safety and effectiveness of IV AS in returning travellers with severe FM.

Methods: We identified adults admitted to the Infectious Diseases unit with severe FM and treated with IV Q (1991–2009) or IV AS (2009–2011). Outcomes included adverse events, mortality, length of stay, admission to intensive care and, where data were available, parasite/fever clearance time and hypoglycaemic events.

Results: Of 167 patients, 24 received IV AS and 143 IV Q. There was one potential AS-associated adverse event, a case of late onset haemolysis. Median length of stay (LOS) was significantly shorter for AS (3·5 versus 5 days, P = 0·017), even after adjusting for African ethnicity (for LOS ⩾3 days, mhor = 0·33, P = 0·027; crude OR = 0·29, P = 0·013). In the AS group, there were no fatalities (versus five in Q group, NS) and fewer intensive care unit (ICU) admissions (NS). Median parasite clearance was significantly faster in AS (65 versus 85 hours in Q, P = 0·0045) with no hypoglycaemic episodes (versus five in Q).

Discussion: We found IV AS to be safe and effective, with shorter LOS, faster parasite and fever clearance, no fatalities or hypoglycaemic events, and fewer ICU admissions versus IV Q. This corroborates both developing world trials and smaller European case series (although these lacked comparison groups). As well as obvious benefits for patients, there are potential resource savings. A case of late-onset haemolysis may represent an adverse event, particularly as it has been documented elsewhere, warranting further investigation. Nonetheless, our experience suggests IV AS should be first-line for treating severe FM in the UK.

Keywords:

• Falciparum malaria
• Severe malaria
• Artesunate
• Quinine
• Safety
• Side effects
• Adverse event
• Hameolytic anaemia
• Effectiveness
• Clinical outcome
• Length of stay
• Parasite clearance
• Returning traveler
• UK
• Non-endemic countries

We expressed our sincere thanks to Geoffrey Pasvol, Professor of Infection & Tropical Medicine at Imperial College London, for his encouragement and our helpful discussions on the subject. We extend our thanks also to the junior doctors who contributed to the maintenance of our departmental malaria database over the years.