Severe malaria is usually treated with intravenous quinine PLUS oral doxycycline (if over 8 years) or clindamycin (oral, intramuscular or intravenous in younger children). Intravenous drugs must be started immediately and the patient urgently referred to hospital. Look for and manage hypoglycaemia, shock or convulsions.
In future intravenous artesunate will probably replace quinine as it is safer. Rectal artesunate is also an effective emergency treatment.
A loading dose of quinine 20 mg/kg diluted in 5% dextrose water (10 ml/kg) must always be given as a slow infusion over 4 hours and never as a bolus. This is followed by 10 mg/kg 8 hourly intravenously. Change to oral quinine as soon as possible.
Using a combination of drugs for both uncomplicated and severe malaria is more effective and less likely to result in resistance in the community than monotherapy (one drug only). The patient should improve clinically within 48 hours and the fever should settle within 5 days.