Adjunctive management of malaria.
OBJECTIVE
Artesunate treatment reduces mortality in severe malaria when compared with quinine. Nevertheless, severe malaria is associated with mortality rates between 1.4 and 9.5% after hospitalization. This review puts into context the recent developments in understanding the pathophysiology of malaria and how these may be reflected in renewed attempts at improving adjunct therapies. Identifying new adjunct approaches has been particularly difficult for severe malaria because most interventions have either caused harm or failed to confer benefit.


RESULTS
Imaging and postmortem findings in children with severe and cerebral malaria have given impetus to study new interventions that could be added to antimalarial treatment. Some pilot studies have (re)tested different approaches to improve complications of cerebral malaria such as the use of N-acetyl cysteine or mannitol. Fluids administration, blood transfusions and red cell exchanges in severe malaria are controversial and important areas that are also reviewed with new evidence. Other interventions such as measures to increase nitric oxide, manage acute renal failure or optimize artesunate dosing are discussed.


CONCLUSIONS
Outcomes with adjunct therapies for severe malaria have been poor, but as insights into pathophysiological processes are deepened it may be possible eventually to reduce mortality further.
Division of Clinical Sciences, Centre for Infection and Immunity, St. George's University of London, London, UK. s.krishna@sgul.ac.uk
Sanjeev
S
Krishna
D000962:Antimalarials / Q000008:administration & dosage*; D037621:Artemisinins / Q000008:administration & dosage*; D000077332:Artesunate; D001803:Blood Transfusion / Q000379:methods; D005440:Fluid Therapy / Q000379:methods; D006801:Humans; D008288:Malaria / Q000628:therapy*; D016779:Malaria, Cerebral / Q000175:diagnosis / Q000628:therapy; D009569:Nitric Oxide / Q000008:administration & dosage
D000962:Antimalarials; D037621:Artemisinins; D009569:Nitric Oxide; D000077332:Artesunate