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2.2.1

Pre-referral Treatment (Community & Health Centre)

Guidelines for the Treatment of Malaria in Malawi, 6th Edition, 2025. Chapter 1, Severe Malaria.

Treatment

Severe malaria is a medical emergency and treatment should begin immediately, whether the patient presents at the community level, health centre, or a hospital. The commencement of life-saving therapy must not be delayed.

At the community level

When severe malaria is suspected at the community level, pre-referral treatment should be initiated immediately with rectal artesunate and the patient should be referred to the nearest health facility for further evaluation and management.

Rectal artesunate suppositories are for children aged < 6 years only. If referral is not possible within 12 hours, a second dose may be given at 12 hours after the initial dose. Thereafter rectal artesunate may be given every 24 hours. However, this treatment is suboptimal, and every effort should be made to refer the patient as soon as possible.

Table 2.3 — Pre-referral rectal artesunate doses for children < 6 years & Figure 2.1 — Insertion of rectal suppository
Table 2.3 — Pre-referral rectal artesunate doses for children < 6 years & Figure 2.1 — Insertion of rectal suppository. Open the image to zoom.

At the health centre level

The medicine of choice for pre-referral treatment of severe malaria at the health centre level is intramuscular (IM) artesunate. If IM artesunate is unavailable or contraindicated, treat with IM quinine, administered in the thigh not the buttock. If neither is available, rectal artesunate should be used in children < 6 years. For children > 6 years, rectal artesunate is contraindicated. The patient must be referred immediately to a hospital for proper management.

Intramuscular Artesunate

The recommended dose of IM artesunate for infants and children whose body weight is < 20 kg should be 3 mg/kg (0.15 ml/kg). For children weighing 20 kg and above, and adults the dosage should be 2.4 mg/kg (0.12 ml/kg) body weight. Artesunate should be given by intramuscular injection into the upper-outer quarter of anterior thigh and should not be injected into the buttocks.

Figure 2.2 — IM injection site; Tables 2.4 & 2.5 — Required vials for parenteral artesunate by body weight
Figure 2.2 — IM injection site; Tables 2.4 & 2.5 — Required vials for parenteral artesunate by body weight. Open the image to zoom.

Intramuscular Quinine

Intramuscular quinine should be used for pre-referral treatment of severe malaria where IM artesunate is either unavailable or contraindicated. The recommended dose of IM quinine is 10 mg (0.2 ml) per kg body weight. Use a 10 ml sterile syringe to draw 5 ml of sterile water for injection, then draw up 300 mg (1 ml) from an ampoule of quinine. The syringe now contains 50 mg of quinine per ml. Withdraw the appropriate volume and administer into the upper outer thigh. If the volume to be injected exceeds 3 ml, give half into each thigh.

Table 2.6 — Sample dosages of IM quinine by body weight
Table 2.6 — Sample dosages of IM quinine by body weight. Open the image to zoom.

Check doses against the printed guideline and your clinical judgement before treating a patient. Spotted an error? Report it from the contact links below.

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