## First-Line Treatment of Severe P. falciparum Malaria **Key Point:** Intravenous artesunate is the WHO-recommended first-line treatment for severe malaria globally. It has superior efficacy, faster parasite clearance, and lower mortality compared to quinine, with mortality reduction of ~35% in severe malaria. **High-Yield:** Severe malaria criteria include: cerebral malaria, acute kidney injury, pulmonary edema, severe anemia (Hb <7 g/dL), acidosis (pH <7.25), hypoglycemia, parasitemia >5%, or shock. This patient meets multiple criteria (altered mental status, AKI, pulmonary edema, high parasitemia). **Clinical Pearl:** Artesunate must be given parenterally (IV or IM) for severe malaria. After 3 days of parenteral therapy, switch to a complete course of oral ACT (e.g., artemether-lumefantrine) to prevent recrudescence. ### Parenteral Antimalarials for Severe Malaria | Drug | Route | Dosing | Onset | Mortality Reduction | Notes | |------|-------|--------|-------|---------------------|-------| | Artesunate | IV/IM | 2.4 mg/kg at 0, 24, 48 h | Fastest | ~35% vs quinine | WHO first-line; superior in severe malaria | | Quinine | IV/IM | 20 mg/kg loading, then 10 mg/kg 8-hourly | Slower | Baseline | Hypoglycemia risk; cinchonism | | Artemether | IM | 3.2 mg/kg daily × 3 days | Intermediate | ~30% vs quinine | Slower than IV artesunate | **Mnemonic:** **SEVERE** = **S**evere malaria requires **E**xtravenous **V**ery **E**ffective **R**apid **E**limination → **Artesunate**. ### Management Algorithm ```mermaid flowchart TD A[Confirmed P. falciparum]:::outcome --> B{Severe Criteria?}:::decision B -->|Yes| C[IV/IM Artesunate]:::action B -->|No| D{Pregnancy?}:::decision D -->|Yes| E[Quinine]:::action D -->|No| F[ACT or Artemisinin derivative]:::action C --> G[3 days parenteral therapy]:::action G --> H[Switch to oral ACT]:::action H --> I[Complete 3-day course]:::action ```
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