title: Intravenous artesunate versus intravenous quinine in the treatment of severe falciparum malaria: a retrospective evaluation from a UK centre.
abstract: BACKGROUND
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Infection and Tropical Medicine, Lister Unit, Northwick Park Hospital, Harrow, UK.
authors.forename: Marcus
authors.initials: M
authors.lastname: Eder
authors.forename: Hugo
authors.initials: H
authors.lastname: Farne
authors.forename: Tamsin
authors.initials: T
authors.lastname: Cargill
authors.forename: Aula
authors.initials: A
authors.lastname: Abbara
authors.forename: Robert N
authors.initials: RN
authors.lastname: Davidson
mesh_terms: D061605:Administration, Intravenous; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D037621:Artemisinins / Q000008:administration & dosage* / Q000009:adverse effects; D000077332:Artesunate; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology; D005260:Female; D006801:Humans; D007902:Length of Stay; D016778:Malaria, Falciparum / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D008297:Male; D008875:Middle Aged; D011803:Quinine / Q000008:administration & dosage* / Q000009:adverse effects; D012189:Retrospective Studies; D016019:Survival Analysis; D014195:Travel; D016896:Treatment Outcome; D006113:United Kingdom; D055815:Young Adult
chemical_list: D037621:Artemisinins; D000077332:Artesunate; D011803:Quinine