Severe life threatening malaria in endemic areas
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《英国医生杂志》
1 Liverpool School of Tropical Medicine, Liverpool L3 5QA
Introduction
Definition Severe malaria is caused by the protozoan infection of red blood cells with Plasmodium falciparum and comprises a variety of syndromes requiring hospitalisation. Clinically complicated malaria presents with life threatening conditions, which include coma, severe anaemia, renal failure, respiratory distress syndrome, hypoglycaemia, shock, spontaneous haemorrhage, and convulsions. The diagnosis of cerebral malaria should be considered where there is encephalopathy in the presence of malaria parasites. A strict definition of cerebral malaria is unrousable coma and no other cause of encephalopathy (for example, hypoglycaemia, sedative drugs) in the presence of P falciparum infection. This review does not include the treatment of malaria in pregnancy.
What are the effects of medical treatment for complicated falciparum malaria in non-pregnant people?
Likely to be beneficial
Two systematic reviews and one subsequent randomised controlled trial (RCT) found no significant difference between artemether versus quinine for preventing death in people with severe malaria.
High first dose quinine
One systematic review and one additional RCT found no significant difference in mortality between quinine regimens with high initial quinine dose versus no loading dose. The systematic review found that high first dose of quinine reduced parasite clearance time and duration of fever compared with no loading dose.
Quinine
We found no RCTs comparing quinine versus placebo or no treatment, but there is consensus that treatment is likely to be beneficial.
Rectal artemisinin
One systematic review found no significant difference in mortality with rectal artemisinin versus quinine.
Unknown effectiveness
Two RCTs in children found no significant difference in mortality with chloroquine versus quinine. However, these RCTs were conducted in the Gambia between 1988 and 1994, when chloroquine resistance was uncommon.
Desferrioxamine mesylate
One systematic review found weak evidence that desferrioxamine mesylate versus placebo reduced the risk of persistent seizures in children with cerebral malaria.
Exchange blood transfusion
One systematic review has found no suitable RCTs.
Initial blood transfusion
One systematic review found no significant difference in deaths in clinically stable children who received an initial blood transfusion for malarial anaemia; it found more adverse events.
Intramuscular versus intravenous quinine
One RCT in children found no significant difference with intramuscular versus intravenous quinine in recovery times or deaths in Kenya in 1990.
Sulfadoxine-pyrimethamine versus quinine
One RCT found that sulfadoxine-pyrimethamine versus quinine cleared parasites faster in children with complicated non-cerebral malaria in 1992-4 in the Gambia, but it found no significant difference in mortality.
Likely to be ineffective or harmful
One systematic review found no significant difference in mortality with dexamethasone versus placebo, but gastrointestinal bleeding and seizures were more common with dexamethasone.
Clinical Evidence (www.clinicalevidence.com) is a compendium of the best available evidence on common and important clinical questions
Search date October 2002
In the next update of Clinical Evidence (issue 11), the options on chloroquine and sulfadoxine-pyrimethamine will be removed at the authors' request on the grounds of clinical relevance (see commentary).
The full content of Clinical Evidence (and Clinical Evidence Concise) is available online (www.clinicalevidence.com); topics are updated every eight months.(Aika Omari, research asso)
Introduction
Definition Severe malaria is caused by the protozoan infection of red blood cells with Plasmodium falciparum and comprises a variety of syndromes requiring hospitalisation. Clinically complicated malaria presents with life threatening conditions, which include coma, severe anaemia, renal failure, respiratory distress syndrome, hypoglycaemia, shock, spontaneous haemorrhage, and convulsions. The diagnosis of cerebral malaria should be considered where there is encephalopathy in the presence of malaria parasites. A strict definition of cerebral malaria is unrousable coma and no other cause of encephalopathy (for example, hypoglycaemia, sedative drugs) in the presence of P falciparum infection. This review does not include the treatment of malaria in pregnancy.
What are the effects of medical treatment for complicated falciparum malaria in non-pregnant people?
Likely to be beneficial
Two systematic reviews and one subsequent randomised controlled trial (RCT) found no significant difference between artemether versus quinine for preventing death in people with severe malaria.
High first dose quinine
One systematic review and one additional RCT found no significant difference in mortality between quinine regimens with high initial quinine dose versus no loading dose. The systematic review found that high first dose of quinine reduced parasite clearance time and duration of fever compared with no loading dose.
Quinine
We found no RCTs comparing quinine versus placebo or no treatment, but there is consensus that treatment is likely to be beneficial.
Rectal artemisinin
One systematic review found no significant difference in mortality with rectal artemisinin versus quinine.
Unknown effectiveness
Two RCTs in children found no significant difference in mortality with chloroquine versus quinine. However, these RCTs were conducted in the Gambia between 1988 and 1994, when chloroquine resistance was uncommon.
Desferrioxamine mesylate
One systematic review found weak evidence that desferrioxamine mesylate versus placebo reduced the risk of persistent seizures in children with cerebral malaria.
Exchange blood transfusion
One systematic review has found no suitable RCTs.
Initial blood transfusion
One systematic review found no significant difference in deaths in clinically stable children who received an initial blood transfusion for malarial anaemia; it found more adverse events.
Intramuscular versus intravenous quinine
One RCT in children found no significant difference with intramuscular versus intravenous quinine in recovery times or deaths in Kenya in 1990.
Sulfadoxine-pyrimethamine versus quinine
One RCT found that sulfadoxine-pyrimethamine versus quinine cleared parasites faster in children with complicated non-cerebral malaria in 1992-4 in the Gambia, but it found no significant difference in mortality.
Likely to be ineffective or harmful
One systematic review found no significant difference in mortality with dexamethasone versus placebo, but gastrointestinal bleeding and seizures were more common with dexamethasone.
Clinical Evidence (www.clinicalevidence.com) is a compendium of the best available evidence on common and important clinical questions
Search date October 2002
In the next update of Clinical Evidence (issue 11), the options on chloroquine and sulfadoxine-pyrimethamine will be removed at the authors' request on the grounds of clinical relevance (see commentary).
The full content of Clinical Evidence (and Clinical Evidence Concise) is available online (www.clinicalevidence.com); topics are updated every eight months.(Aika Omari, research asso)