Severe quinine-resistant malaria is exceptionally rare at present. It is currently (1997) a clinical problem in a very restricted area of Southeast Asia. Patients who come from the Thai-Burmese or Thai-Cambodian borders should be considered potentially to have quinine resistance, and alternative drugs should be considered. Resistance patterns change rapidly, and up-to-date information about them should be sought in these patients. Only artemisinine derivatives can reliably take the place of quinine for parenteral treatment, and currently these are available only on a named-patient basis in Europe and America. The alternatives are as follows.
1. Artesunate (as sodium artesunate) diluted in 5 to 10 ml of 5 per cent glucose by intravenous or intramuscular injection. The initial dose is 2.4 mg/kg, followed by 1.2 mg/kg at 12 and 24 h, and daily thereafter (Hie_D__aD_d__White 1993).
2. Artemether by intramuscular injection. The initial dose is 3.2 mg/kg, followed by 1.6 mg/kg daily.
Both should be followed by a second-line drug. Reports of increased incidence of neurotoxicity with mefloquine make other choices of second-line drugs, such as doxycycline, more attractive.
Where artemesinine derivatives are not available, combined therapy using quinine or quinidine as above with doxycycline up to 3 mg/kg/day will reduce failure rates in quinine resistance.
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