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Abstract
Tetanus is a vaccine-preventable disease that still commonly occurs in many low-income and middle-income countries, although it is rare in high-income countries. The disease is caused by the toxin of the bacterium Clostridium tetani and is characterised by muscle spasms and autonomic nervous system dysfunction. Global vaccination initiatives have had considerable success but they continue to face many challenges. Treatment for tetanus aims to control spasms and reduce cardiovascular instability, and consists of wound debridement, antitoxin, antibiotics, and supportive care. Recent research has focused on intravenous magnesium sulphate and intrathecal antitoxin administration as methods of spasm control that can avoid the need for ventilatory support. Nevertheless, without access to mechanical ventilation, mortality from tetanus remains high. Even with such care, patients require several weeks of hospitalisation and are vulnerable to secondary problems, such as hospital-acquired infections.
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Affiliation(s)
- Lam Minh Yen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
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Noubiap JJN. Shifting from quinine to artesunate as first-line treatment of severe malaria in children and adults: Saving more lives. J Infect Public Health 2014; 7:407-12. [DOI: 10.1016/j.jiph.2014.04.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 02/21/2014] [Accepted: 04/26/2014] [Indexed: 11/28/2022] Open
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Abstract
The prevalence of tetanus reflects a failure of immunization. Prompt diagnosis and prediction of severity are crucial for the prevention of early life threatening complications and the institution of appropriate management. The current symptomatic treatment of heavy sedation, paralysis and artificial ventilation for 3-5 weeks for moderate and severe tetanus, is, even in the best centers, still associated with unacceptably high mortality, due to the disease and complications of the therapy itself. It is especially inappropriate for the developing world where intensive care resources are minimal. New options reported to avoid artificial ventilation and sedation are dantrolene (Dantrium, Procter and Gamble Pharmaceuticals), baclofen (Lioresal, Novartis) and magnesium. Magnesium therapy has the advantages of controlling spasms and sympathetic over activity without sedation. This simplifies nursing care and minimizes the need for ventilatory support except in the very severe disease and the elderly. Magnesium is recommended as the first-line therapy in tetanus.
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Gangrène gazeuse bilatérale des membres inférieurs, consécutive à des injections intramusculaires de quinine. Presse Med 2013; 42:1415-8. [DOI: 10.1016/j.lpm.2012.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 10/25/2012] [Indexed: 11/17/2022] Open
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Verma R, Khanna P. Tetanus toxoid vaccine: elimination of neonatal tetanus in selected states of India. Hum Vaccin Immunother 2012; 8:1439-42. [PMID: 22894950 PMCID: PMC3660763 DOI: 10.4161/hv.21145] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Accepted: 06/18/2012] [Indexed: 11/19/2022] Open
Abstract
Tetanus is caused by a neurotoxin produced by Clostridium tetani (C. tetani), a spore-forming bacterium. Infection begins when tetanus spores are introduced into damaged tissue. Tetanus is characterized by muscle rigidity and painful muscle spasms caused by tetanus toxin's blockade of inhibitory neurons that normally oppose and modulate the action of excitatory motor neurons. Maternal and neonatal tetanus (MNT) are caused by unhygienic methods of delivery, abortion, or umbilical-cord care. Maternal and neonatal tetanus are both forms of generalized tetanus and have similar clinical courses. About 90% of neonates with tetanus develop symptoms in the first 3-14 d of life, mostly on days 6-8, distinguishing neonatal tetanus from other causes of neonatal mortality which typically occur during the first two days of life. Overall case fatality rates for patients admitted to the hospital with neonatal tetanus in developing countries are 8-50%, while the fatality rate can be as high as 100% without hospital care. Tetanus toxoid (TT) vaccination of pregnant women to prevent neonatal tetanus was included in WHO's Expanded Program on Immunization (EPI) a few years after its inception in 1974. In 2000, WHO, UNICEF, and UNFPA formed a partnership to relaunch efforts toward this goal, adding the elimination of maternal tetanus as a program objective, and setting a new target date of 2005. By February 2007, 40 countries had implemented tetanus vaccination campaigns in high-risk areas, targeting more than 94 million women, and protecting more than 70 million subjects with at least two doses of TT. In 2011, 653 NT cases were reported in India compared with 9313 in 1990. As of February 2012, 25 countries and 15 States and Union Territories of India, all of Ethiopia except Somaliland, and almost 29 of 34 provinces in Indonesia have been validated to have eliminated MNT.
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Affiliation(s)
- Ramesh Verma
- Pt BDS PGIMS; Community Medicine; Rohtak, Haryana India
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Loan HT, Parry J, Nga NTN, Yen LM, Binh NT, Thuy TTD, Duong NM, Campbell JI, Thwaites L, Farrar JJ, Parry CM. Semi-recumbent body position fails to prevent healthcare-associated pneumonia in Vietnamese patients with severe tetanus. Trans R Soc Trop Med Hyg 2012; 106:90-7. [PMID: 22197012 PMCID: PMC3368426 DOI: 10.1016/j.trstmh.2011.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 10/07/2011] [Accepted: 10/07/2011] [Indexed: 10/25/2022] Open
Abstract
Healthcare-associated pneumonia (HCAP) is a common complication in patients with severe tetanus. Nursing tetanus patients in a semi-recumbent body position could reduce the incidence of HCAP. In a randomised controlled trial we compared the occurrence of HCAP in patients with severe tetanus nursed in a semi-recumbent (30°) or supine position. A total of 229 adults and children (aged ≥1 year) with severe tetanus admitted to hospital in Vietnam, were randomly assigned to a supine (n=112) or semi-recumbent (n=117) position. For patients maintaining their assigned positions and in hospital for>48h there was no significant difference between the two groups in the frequency of clinically suspected pneumonia [22/106 (20.8%) vs 26/104 (25.0%); p=0.464], pneumonia rate/1000 intensive care unit days (13.9 vs 14.6; p=0.48) and pneumonia rate/1000 ventilated days (39.2 vs 38.1; p=0.72). Mortality in the supine patients was 11/112 (9.8%) compared with 17/117 (14.5%) in the semi-recumbent patients (p=0.277). The overall complication rate [57/112 (50.9%) vs 76/117 (65.0%); p=0.03] and need for tracheostomy [51/112 (45.5%) vs 69/117 (58.9%); p=0.04) was greater in semi-recumbent patients. Semi-recumbent body positioning did not prevent the occurrence of HCAP in severe tetanus patients.
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Affiliation(s)
- Huynh Thi Loan
- Hospital for Tropical Diseases, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam
| | - Janet Parry
- The Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, 190 Ben Ham Tu, District 5, Ho Chi Minh City Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Nguyen Thi Ngoc Nga
- Hospital for Tropical Diseases, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam
| | - Lam Minh Yen
- Hospital for Tropical Diseases, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam
| | - Nguyen Thien Binh
- Hospital for Tropical Diseases, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam
| | - Tran Thi Diem Thuy
- Hospital for Tropical Diseases, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam
| | - Nguyen Minh Duong
- Hospital for Tropical Diseases, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam
| | - James I. Campbell
- The Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, 190 Ben Ham Tu, District 5, Ho Chi Minh City Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Louise Thwaites
- The Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, 190 Ben Ham Tu, District 5, Ho Chi Minh City Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jeremy J. Farrar
- The Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, 190 Ben Ham Tu, District 5, Ho Chi Minh City Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Christopher M. Parry
- The Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, 190 Ben Ham Tu, District 5, Ho Chi Minh City Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Lubell Y, Riewpaiboon A, Dondorp AM, von Seidlein L, Mokuolu OA, Nansumba M, Gesase S, Kent A, Mtove G, Olaosebikan R, Ngum WP, Fanello CI, Hendriksen I, Day NPJ, White NJ, Yeung S. Cost-effectiveness of parenteral artesunate for treating children with severe malaria in sub-Saharan Africa. Bull World Health Organ 2011; 89:504-12. [PMID: 21734764 DOI: 10.2471/blt.11.085878] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 03/30/2011] [Accepted: 03/30/2011] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To explore the cost-effectiveness of parenteral artesunate for the treatment of severe malaria in children and its potential impact on hospital budgets. METHODS The costs of inpatient care of children with severe malaria were assessed in four of the 11 sites included in the African Quinine Artesunate Malaria Treatment trial, conducted with over 5400 children. The drugs, laboratory tests and intravenous fluids provided to 2300 patients from admission to discharge were recorded, as was the length of inpatient stay, to calculate the cost of inpatient care. The data were matched with pooled clinical outcomes and entered into a decision model to calculate the cost per disability-adjusted life year (DALY) averted and the cost per death averted. FINDINGS The mean cost of treating severe malaria patients was similar in the two study groups: 63.5 United States dollars (US$) (95% confidence interval, CI: 61.7-65.2) in the quinine arm and US$ 66.5 (95% CI: 63.7-69.2) in the artesunate arm. Children treated with artesunate had 22.5% lower mortality than those treated with quinine and the same rate of neurological sequelae: (artesunate arm: 2.3 DALYs per patient; quinine arm: 3.0 DALYs per patient). Compared with quinine as a baseline, artesunate showed an incremental cost per DALY averted and an incremental cost per death averted of US$ 3.8 and US$ 123, respectively. CONCLUSION Artesunate is a highly cost-effective and affordable alternative to quinine for treating children with severe malaria. The budgetary implications of adopting artesunate for routine use in hospital-based care are negligible.
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Affiliation(s)
- Yoel Lubell
- Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Bangkok, 10400,Thailand
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10
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Dondorp AM, Fanello CI, Hendriksen ICE, Gomes E, Seni A, Chhaganlal KD, Bojang K, Olaosebikan R, Anunobi N, Maitland K, Kivaya E, Agbenyega T, Nguah SB, Evans J, Gesase S, Kahabuka C, Mtove G, Nadjm B, Deen J, Mwanga-Amumpaire J, Nansumba M, Karema C, Umulisa N, Uwimana A, Mokuolu OA, Adedoyin OT, Johnson WBR, Tshefu AK, Onyamboko MA, Sakulthaew T, Ngum WP, Silamut K, Stepniewska K, Woodrow CJ, Bethell D, Wills B, Oneko M, Peto TE, von Seidlein L, Day NPJ, White NJ. Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. Lancet 2010; 376:1647-57. [PMID: 21062666 PMCID: PMC3033534 DOI: 10.1016/s0140-6736(10)61924-1] [Citation(s) in RCA: 655] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Severe malaria is a major cause of childhood death and often the main reason for paediatric hospital admission in sub-Saharan Africa. Quinine is still the established treatment of choice, although evidence from Asia suggests that artesunate is associated with a lower mortality. We compared parenteral treatment with either artesunate or quinine in African children with severe malaria. METHODS This open-label, randomised trial was undertaken in 11 centres in nine African countries. Children (<15 years) with severe falciparum malaria were randomly assigned to parenteral artesunate or parenteral quinine. Randomisation was in blocks of 20, with study numbers corresponding to treatment allocations kept inside opaque sealed paper envelopes. The trial was open label at each site, and none of the investigators or trialists, apart from for the trial statistician, had access to the summaries of treatment allocations. The primary outcome measure was in-hospital mortality, analysed by intention to treat. This trial is registered, number ISRCTN50258054. FINDINGS 5425 children were enrolled; 2712 were assigned to artesunate and 2713 to quinine. All patients were analysed for the primary outcome. 230 (8·5%) patients assigned to artesunate treatment died compared with 297 (10·9%) assigned to quinine treatment (odds ratio [OR] stratified for study site 0·75, 95% CI 0·63-0·90; relative reduction 22·5%, 95% CI 8·1-36·9; p=0·0022). Incidence of neurological sequelae did not differ significantly between groups, but the development of coma (65/1832 [3·5%] with artesunate vs 91/1768 [5·1%] with quinine; OR 0·69 95% CI 0·49-0·95; p=0·0231), convulsions (224/2712 [8·3%] vs 273/2713 [10·1%]; OR 0·80, 0·66-0·97; p=0·0199), and deterioration of the coma score (166/2712 [6·1%] vs 208/2713 [7·7%]; OR 0·78, 0·64-0·97; p=0·0245) were all significantly less frequent in artesunate recipients than in quinine recipients. Post-treatment hypoglycaemia was also less frequent in patients assigned to artesunate than in those assigned to quinine (48/2712 [1·8%] vs 75/2713 [2·8%]; OR 0·63, 0·43-0·91; p=0·0134). Artesunate was well tolerated, with no serious drug-related adverse effects. INTERPRETATION Artesunate substantially reduces mortality in African children with severe malaria. These data, together with a meta-analysis of all trials comparing artesunate and quinine, strongly suggest that parenteral artesunate should replace quinine as the treatment of choice for severe falciparum malaria worldwide. FUNDING The Wellcome Trust.
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Affiliation(s)
- Arjen M Dondorp
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Caterina I Fanello
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ilse CE Hendriksen
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Amir Seni
- Hospital Central da Beira, Beira, Mozambique
| | | | | | | | | | | | | | | | | | | | - Samwel Gesase
- Magunga District Hospital, NIMR-Korogwe Research Laboratory, Tanga, Tanzania
| | - Catherine Kahabuka
- Magunga District Hospital, NIMR-Korogwe Research Laboratory, Tanga, Tanzania
| | | | - Behzad Nadjm
- Teule Designated District Hospital, Muheza, Tanzania
| | | | | | - Margaret Nansumba
- Mbarara University of Science and Technology and Epicentre Research Base, Mbarara, Uganda
| | - Corine Karema
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Noella Umulisa
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Aline Uwimana
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | | | | | | | - Antoinette K Tshefu
- Kinshasa School of Public Health—Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Marie A Onyamboko
- Kinshasa School of Public Health—Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Tharisara Sakulthaew
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirichada Pan Ngum
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kamolrat Silamut
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kasia Stepniewska
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charles J Woodrow
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Delia Bethell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Bridget Wills
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Tim E Peto
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Nicholas PJ Day
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Correspondence to: Prof N J White, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand
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11
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Eisenhut M, Omari AAA. Intrarectal quinine versus intravenous or intramuscular quinine for treating Plasmodium falciparum malaria. Cochrane Database Syst Rev 2009; 2009:CD004009. [PMID: 19160229 PMCID: PMC6532585 DOI: 10.1002/14651858.cd004009.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In children with falciparum malaria, a proprietary quinine preparation (adjusted to make it less acidic) administered rectally may be easier to use and less painful than intramuscular or intravenous administration. However, rectal quinine may be less effective. OBJECTIVES To compare intrarectal quinine with intravenous or intramuscular quinine for treating malaria caused by Plasmodium falciparum. SEARCH STRATEGY In May 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, LILACS, and CINAHL. We also searched conference proceedings, contacted individual researchers and a pharmaceutical company, and checked reference lists. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing intrarectal quinine with intramuscular and intravenous quinine for treating people with uncomplicated and severe Plasmodium falciparum malaria. DATA COLLECTION AND ANALYSIS We independently assessed each trial's risk of bias quality and extracted data, including adverse event data. We analysed dichotomous data using the odds ratio and continuous data using the mean difference. MAIN RESULTS Ten randomized controlled trials, all involving children only (total of 1417 children), fulfilled the inclusion criteria. The same investigator was involved in nine of the trials. Seven trials compared proprietary intrarectal with intravenous quinine, and seven trials compared it with intramuscular treatment. We detected no statistically significant difference between intrarectal and intravenous or intramuscular routes for death, parasite clearance by 48 hours and seven days, parasite clearance time, fever clearance time, coma recovery time, duration of hospitalization, and time to drinking. The trials reporting on these outcomes were small, which resulted in large confidence intervals for all outcomes apart from duration of hospitalization. One large trial (898 children) reported that intrarectal was less painful than intramuscular administration. AUTHORS' CONCLUSIONS We detected no difference in the effect on parasites and clinical illness for intrarectal quinine, but most trials were small. Pain may be less with intrarectal proprietary, buffered quinine preparations (made less acidic by adjustment of the pH to 4.5). Further larger trials in patients with severe malaria and in adults are required before the intrarectal route can be recommended.
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Affiliation(s)
- Michael Eisenhut
- Paediatric Department, Luton & Dunstable Hospital NHS Foundation Trust, Lewsey Road, Luton, UK, LU4 0DZ.
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Boumandouki P, Kounkou RY, Teke-Bagamboula JN, Ekouele Mbaki H, Ndinga E. [Intramuscular injections of quinine and tetanus at the Centre Hospitalier Universitaire of Brazzaville, Congo]. ACTA ACUST UNITED AC 2008; 101:298-300. [PMID: 18956808 DOI: 10.3185/pathexo3054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intramuscular injections are known for their iatrogenic complications. IM quinine is a routine procedure in Congo for drug resistant malaria management. In this short note, the authors evaluate tetanus relative to intramuscular injection of quinine among the cases of tetanus treated in the infectious diseases unit of "Centre Hospitalier Universitaire of Brazzaville". This study was conducted from January to December 2005 regarding 18 cases of tetanus among which 5 infected after intramuscular injection of quinine. Their level of severity was significantly higher with a high mortality rate (post intramuscular: 4 deaths out of 5; other cases: 3 deaths out of 13). Tetanus was generalized in 17 cases. A significant difference between the intramuscular and the non-intramuscular injection was observed regarding the pulse (p < 0.05), the level of severity (p < 0.005) and deaths (p < 0.005). Awareness-raising campaigns with populations and medical staff about the risks of intramuscular injections as well as vaccination schedule should be regularly implemented.
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Affiliation(s)
- P Boumandouki
- Service des maladies infectieuses BP:32, Centre hospitalier universitaire de Brazzaville, Congo.
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13
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Brook I. Current concepts in the management of Clostridium tetaniinfection. Expert Rev Anti Infect Ther 2008; 6:327-336. [DOI: 10.1586/14787210.6.3.327] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Abstract
Tetanus remains an important disease worldwide. In the United Kingdom, the elderly and intravenous drug users are at particular risk of acquiring clinical tetanus. Tetanus is associated with a high morbidity and mortality. Once the diagnosis of tetanus is suspected, intensive management is necessary. In this article we review the history, epidemiology, microbiology, clinical features, mode of transmission, pathogenesis, differential diagnosis, management, complications and prevention of this life threatening disease.
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Affiliation(s)
- I H Mallick
- University Dept of Surgery, Royal Free & University College Medical School, London, UK.
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15
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Abstract
Maternal and neonatal tetanus are important causes of maternal and neonatal mortality, claiming about 180 000 lives worldwide every year, almost exclusively in developing countries. Although easily prevented by maternal immunisation with tetanus toxoid vaccine, and aseptic obstetric and postnatal umbilical-cord care practices, maternal and neonatal tetanus persist as public-health problems in 48 countries, mainly in Asia and Africa. Survival of tetanus patients has improved substantially for those treated in hospitals with modern intensive-care facilities; however, such facilities are often unavailable where the tetanus burden is highest. The Maternal and Neonatal Tetanus Elimination Initiative assists countries in which maternal and neonatal tetanus has not been eliminated to provide immunisation with tetanus toxoid to women of childbearing age. The ultimate goal of this initiative is the worldwide elimination of maternal and neonatal tetanus. Since tetanus spores cannot be removed from the environment, sustaining elimination will require improvements to presently inadequate immunisation and health-service infrastructures, and universal access to those services. The renewed worldwide commitment to the reduction of maternal and child mortality, if translated into effective action, could help to provide the systemic changes needed for long-term elimination of maternal and neonatal tetanus.
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Affiliation(s)
- Nicholas Day
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand, and the Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand, and the Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
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17
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Keita AD, Kane M, Doumbia S, Coulibaly Y, Traore S, Toure AY, Diallo AK, Toure AA, Traore I. [Contribution of ultrasound in the diagnosis of the complications of intramuscular injection in children]. BULLETIN DE LA SOCIETE DE PATHOLOGIE EXOTIQUE (1990) 2006; 99:5-8. [PMID: 16568672 DOI: 10.3185/pathexo2822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
During a prospective study conducted at the rehabilitation Center of the physically handicapped persons and at the mother-child Hospital in Bamako, the authors report 50 cases of neuromuscular complications of the quinine intramuscular injection in the child. The scan revealed muscular calcifications in 37 cases (740%), abscesses, in 7 cases (14%) and muscular inflammations in 6 cases (12%). Xray of the affected limb was not systematic: it has been performed in four children in the case of a subjacent bone involment. It showed calcifications in two cases. If muscular abscess is easily diagnosed by clinical exam it is not the case for calcifications. The scan allows to set up a precise mapping of the muscular lesions, to determine their type and size. It also helps the clinicians in their therapeutic attitude. Medical treatment associated with rehabilitation has been carried out in 40 patients (80%) and surgery in 10 patients (20%).
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Affiliation(s)
- A D Keita
- Service de radiologie et d'imagerie médicale de l'Hôpital du Point G, Bamako, Mali.
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Dondorp A, Nosten F, Stepniewska K, Day N, White N. Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet 2005; 366:717-25. [PMID: 16125588 DOI: 10.1016/s0140-6736(05)67176-0] [Citation(s) in RCA: 690] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the treatment of severe malaria, intravenous artesunate is more rapidly acting than intravenous quinine in terms of parasite clearance, is safer, and is simpler to administer, but whether it can reduce mortality is uncertain. METHODS We did an open-label randomised controlled trial in patients admitted to hospital with severe falciparum malaria in Bangladesh, India, Indonesia, and Myanmar. We assigned individuals intravenous artesunate 2.4 mg/kg bodyweight given as a bolus (n=730) at 0, 12, and 24 h, and then daily, or intravenous quinine (20 mg salt per kg loading dose infused over 4 h then 10 mg/kg infused over 2-8 h three times a day; n=731). Oral medication was substituted when possible to complete treatment. Our primary endpoint was death from severe malaria, and analysis was by intention to treat. FINDINGS We assessed all patients randomised for the primary endpoint. Mortality in artesunate recipients was 15% (107 of 730) compared with 22% (164 of 731) in quinine recipients; an absolute reduction of 34.7% (95% CI 18.5-47.6%; p=0.0002). Treatment with artesunate was well tolerated, whereas quinine was associated with hypoglycaemia (relative risk 3.2, 1.3-7.8; p=0.009). INTERPRETATION Artesunate should become the treatment of choice for severe falciparum malaria in adults.
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Affiliation(s)
- Arjen Dondorp
- Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
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Eisenhut M, Omari A, MacLehose HG. Intrarectal quinine for treating Plasmodium falciparum malaria: a systematic review. Malar J 2005; 4:24. [PMID: 15904520 PMCID: PMC1156934 DOI: 10.1186/1475-2875-4-24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2005] [Accepted: 05/18/2005] [Indexed: 11/10/2022] Open
Abstract
Background In children with malaria caused by Plasmodium falciparum, quinine administered rectally may be easier to use and less painful than intramuscular or intravenous administration. The objective of this review was to compare the effectiveness of intrarectal with intravenous or intramuscular quinine for treating falciparum malaria. Methods All randomized and quasi-randomized controlled trials comparing intrarectal with intramuscular or intravenous quinine for treating people with falciparum malaria located through the following sources were included: Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS and CINAHL. Trial quality was assessed and data, including adverse event data, were extracted. Dichotomous data were analysed using odds ratios and continuous data using weighted mean difference. Results Eight randomized controlled trials (1,247 children) fulfilled the inclusion criteria. The same principal investigator led seven of the trials. Five compared intrarectal with intravenous quinine, and six compared intrarectal with intramuscular treatment. No statistically significant difference was detected for death, parasite clearance by 48 hours and seven days, parasite and fever clearance time, coma recovery time, duration of hospitalization and time before drinking began. One trial (898 children) reported that intrarectal was less painful than intramuscular administration. Conclusion No difference in the effect on parasites and clinical illness was detected for the use of intrarectal quinine compared with other routes, but most trials were small. Pain during application may be less with intrarectal quinine. Further larger trials, in patients with severe malaria and in adults, are required before the intrarectal route could be recommended.
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Affiliation(s)
- Michael Eisenhut
- Arrowe Park Hospital, Wirral Hospital NHS Trust, Upton, Wirral, UK
| | - Aika Omari
- Paediatric Department, Glan Clwyd Hospital, Clwyd, UK
| | - Harriet G MacLehose
- International Health Research Group, Liverpool School of Tropical Medicine, Liverpool, UK
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Wasay M, Khealani BA, Talati N, Shamsi R, Syed NA, Salahuddin N. Autonomic nervous system dysfunction predicts poor prognosis in patients with mild to moderate tetanus. BMC Neurol 2005; 5:2. [PMID: 15679900 PMCID: PMC548694 DOI: 10.1186/1471-2377-5-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2004] [Accepted: 01/31/2005] [Indexed: 11/17/2022] Open
Abstract
Background Autonomic nervous system (ANS) dysfunction is present in up to one third of patients with tetanus. The prognostic value of ANS dysfunction is known in severe tetanus but its value is not well established in mild to moderate tetanus. Methods Medical records of all patients admitted with tetanus at two academic tertiary care centers in Karachi, Pakistan were reviewed. The demographic, clinical and laboratory data was recorded and analyzed. ANS dysfunction was defined as presence of labile or persistent hypertension or hypotension and sinus tachycardia, tachyarrythmia or bradycardia on EKG. Patients were divided into two groups based on presence of ANS dysfunction (ANS group and non ANS group). Tetanus severity was classified on the basis of Ablett criteria. Results Ninety six (64 males; 32 females) patients were admitted with the diagnosis over a period of 10 years. ANS group had 31 (32%) patients while non ANS group comprised of 65 (68%) patients. Both groups matched for age, gender, symptom severity, use of tetanus immunoglobulin and antibiotics. Twelve patients in ANS group had mild to moderate tetanus (Ablett I and II) and 19 patients had severe/very severe tetanus (Ablett III and IV). Fifteen (50%) patients in ANS group required ventilation as compared to 28 (45%) in non-ANS group (p = 0.09). Fourteen (47%) patients died in ANS group as compared to 10 (15%) in non ANS group (p= 0.002). Out of those 14 patients died in ANS group, six patients had mild to moderate tetanus and eight patients had severe/ very severe tetanus. Major cause of death was cardiac arrhythmias (13/14; 93%) in ANS group and respiratory arrest (7/10; 70%) in non ANS group. Ten (33%) patients had complete recovery in ANS group while in non ANS group 35(48%) patients had complete recovery (p= 0.05). Conclusions ANS dysfunction was present in one third of our tetanus population. 40% patients with ANS dysfunction had only mild to moderate tetanus. ANS dysfunction, irrespective of the need of mechanical ventilation or severity of tetanus, predicted poor outcome.
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Affiliation(s)
- Mohammad Wasay
- Department of Neurology, The Aga Khan University, Karachi, Pakistan
| | - Bhojo A Khealani
- Department of Neurology, The Aga Khan University, Karachi, Pakistan
| | - Naasha Talati
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Rohmah Shamsi
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Nadir A Syed
- Department of Neurology, The Aga Khan University, Karachi, Pakistan
| | - Naseem Salahuddin
- Department of Medicine, Liaquat National Hospital, Karachi, Pakistan
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Abstract
BACKGROUND In children with falciparum malaria, quinine administered rectally may be easier to use and less painful than intramuscular or intravenous administration. However, it may be less effective. OBJECTIVES To compare intrarectal quinine with intravenous or intramuscular quinine for treating malaria caused by Plasmodium falciparum. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (July 2004), CENTRAL (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to July 2004), EMBASE (1974 to July 2004), LILACS (1982 to July 2004), and CINAHL (1982 to July 2004). We also searched conference proceedings, contacted individual researchers and a pharmaceutical company, and checked reference lists. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing intrarectal quinine with intramuscular and intravenous quinine for treating people with uncomplicated and severe falciparum malaria. DATA COLLECTION AND ANALYSIS We independently assessed trial quality and extracted data, including adverse event data. We analysed dichotomous data using odds ratios and weighted mean difference for continuous data. MAIN RESULTS Eight randomized controlled trials (involving 1247 children) fulfilled the inclusion criteria. The same principal investigator led seven of the trials. Five trials compared intrarectal with intravenous quinine, and six trials compared it with intramuscular treatment. We detected no statistically significant difference between intrarectal and intravenous or intramuscular routes for death, parasite clearance by 48 hours and 7 days, parasite clearance time, fever clearance time, coma recovery time, duration of hospitalization, and time to drinking. The trials reporting on these outcomes were small, which resulted in large confidence intervals for all outcomes apart from duration of hospitalization. One large trial (898 children) reported that intrarectal was less painful than intramuscular administration. AUTHORS' CONCLUSIONS We detected no difference in the effect on parasites and clinical illness for intrarectal quinine, but most trials were small. Pain may be less with intrarectal quinine. Further larger trials, in patients with severe malaria and in adults, are required before the intrarectal route can be recommended.
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Affiliation(s)
- M Eisenhut
- University of Liverpool, 5 Prestwood Crescent, Liverpool, UK, L14 2ED.
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22
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Fawaz F, Koffi A, Guyot M, Millet P. Comparative in vitro–in vivo study of two quinine rectal gel formulations. Int J Pharm 2004; 280:151-62. [PMID: 15265555 DOI: 10.1016/j.ijpharm.2004.05.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2003] [Revised: 05/05/2004] [Accepted: 05/11/2004] [Indexed: 10/26/2022]
Abstract
The main objective of this work was to develop and evaluate rectal quinine paediatric formulations to treat acute uncomplicated malaria attack in some African countries. Developed dosage forms must be able to assure a prolonged release in the rectum but not too much so as to avoid product expulsion by the child anus. Two quinine rectal gels, namely mucoadhesive (MA) gel and thermosensitive (TS) gel, containing 20 mg quinine base/g were developed and evaluated in vitro and in vivo in the rabbit. The MA and the TS gels contained hydroxypropyl methylcellulose 4000 (HPMC) and poloxamer 407, respectively. The calculated in vitro release exponent (n) values suggested that drug was released from both gels by non-Fickian diffusion. Both gels exhibit practically similar efficient of dissolution (ED%) which was not reflected in the plasma and, therefore, quinine bioavailability from MA gel was found to be higher than that obtained from TS gel and their AUC(0-infinity) were statistically different (P = 0.0006). The t(1/2) values of quinine were significantly higher for Hydrogels than for IV and rectal solutions. MRT values displayed by TS gel and MA gel were not statistically different but were about 3.8- and 1.3-fold, respectively, larger than those obtained for IV solution and rectal solution, respectively. These results confirm the sustained-release behaviour of both hydrogels in the rabbit. Tolerability study of hydrogels didn't show any damage on the rectal mucosa of the rabbit.
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Affiliation(s)
- F Fawaz
- Laboratoire de Pharmacie Galénique et Biopharmacie, EA 3677, Université Victor Segalen Bordeaux 2, 146 Rue Léo Saignat, 33076 Bordeaux Cedex, France.
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Abstract
Malaria, caused mostly by Plasmodium falciparum and P. vivax, remains one of the most important infectious diseases in the world. Antimalarial drug toxicity is one side of the risk-benefit equation and is viewed differently depending upon whether the clinical indication for drug administration is malaria treatment or prophylaxis. Drug toxicity must be acceptable to patients and cause less harm than the disease itself. Research that leads to drug registration tends to omit two important groups who are particularly vulnerable to malaria--very young children and pregnant women. Prescribing in pregnancy is a particular problem for clinicians because the risk-benefit ratio is often very unclear. The number of antimalarial drugs in use is very small. Despite its decreasing efficacy against P. falciparum, chloroquine continues to be used widely because of its low cost and good tolerability. It remains the drug of first choice for treating P. vivax malaria. Pruritus is a common adverse effect in African patients. As prophylaxis, chloroquine is usually combined with proguanil. This combination has good overall tolerability but mouth ulcers and gastrointestinal upset are more common than with other prophylactic regimens. Sulfadoxine/pyrimethamine is well tolerated as treatment and when used as intermittent preventive treatment in pregnant African women. Sulfadoxine/pyrimethamine is no longer used as prophylaxis because it may cause toxic epidermal necrolysis and Stevens Johnson syndrome. Mefloquine remains a valuable drug for prophylaxis and treatment. Tolerability is acceptable to most patients and travellers despite the impression given by the lay press. Dose-related serious neuropsychiatric toxicity can occur; mefloquine is contraindicated in individuals with a history of epilepsy or psychiatric disease. Quinine is the mainstay for treating severe malaria in many countries. Cardiovascular or CNS toxicity is rare, but hypoglycaemia may be problematic and blood glucose levels should be monitored. Halofantrine is unsuitable for widespread use because of its potential for cardiotoxicity. There is renewed interest in two old drugs, primaquine and amodiaquine. Primaquine is being developed as prophylaxis, and amodiaquine, which was withdrawn from prophylactic use because of neutropenia and hepatitis, is a potentially good partner drug for artesunate against falciparum malaria. Atovaquone/proguanil is a new antimalarial combination with good efficacy and tolerability as prophylaxis and treatment. The most important class of drugs that could have a major impact on malaria control is the artemisinin derivatives. They have remarkable efficacy and an excellent safety record. They have no identifiable dose-related adverse effects in humans and only very rarely produce allergic reactions. Combining an artemisinin derivative with another efficacious antimalarial drug is increasingly being viewed as the optimal therapeutic strategy for malaria.
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Krishna S, Nagaraja NV, Planche T, Agbenyega T, Bedo-Addo G, Ansong D, Owusu-Ofori A, Shroads AL, Henderson G, Hutson A, Derendorf H, Stacpoole PW. Population pharmacokinetics of intramuscular quinine in children with severe malaria. Antimicrob Agents Chemother 2001; 45:1803-9. [PMID: 11353629 PMCID: PMC90549 DOI: 10.1128/aac.45.6.1803-1809.2001] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2000] [Accepted: 03/13/2001] [Indexed: 11/20/2022] Open
Abstract
We present the first population pharmacokinetic analysis of quinine in patients with Plasmodium falciparum malaria. Ghanaian children (n = 120; aged 12 months to 10 years) with severe malaria received an intramuscular loading dose of quinine dihydrochloride (20 mg/kg of body weight). A two-compartment model with first-order absorption and elimination gave post hoc estimates for pharmacokinetic parameters that were consistent with those derived from non-population pharmacokinetic studies (clearance [CL] = 0.05 liter/h/kg of body weight; volume of distribution in the central compartment [V(1)] = 0.65 liter/kg; volume of distribution at steady state = 1.41 liter/kg; half-life at beta phase = 19.9 h). There were no covariates (including age, gender, acidemia, anemia, coma, parasitemia, or anticonvulsant use) that explained interpatient variability in weight-normalized CL and V(1). Intramuscular quinine was associated with minor, local toxicity in some patients (13 of 108; 12%), and 11 patients (10%) experienced one or more episodes of postadmission hypoglycemia. A loading dose of intramuscular quinine results in predictable population pharmacokinetic profiles in children with severe malaria and may be preferred to the intravenous route of administration in some circumstances.
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Affiliation(s)
- S Krishna
- Department of Infectious Diseases, St. George's Hospital Medical School, Cranmer Terrace, London SW17 ORE, United Kingdom.
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Abstract
Tetanus is an acute neurological disease characterized by muscle rigidity and spasms, autonomic dysfunction and in severe forms requires respiratory and hemodynamic support. Though it is entirely preventable by immunization, it still occurs in developing countries causing significant morbidity and mortality. Intensive care management of tetanus is fraught with problems of ventilator-associated pneumonia, nosocomial sepsis and a variety of other complications. Various treatment protocols have been tried in managing diverse manifestations of severe tetanus but the consensus is yet to emerge. In this review we have discussed the pathophysiology, clinical features and management controversies and suggest on basis of our experience use of high dose diazepam (20-120 mg/kg/day) and vecuronium with mechanical ventilation if required for control of spasms, and early detection of autonomic dysfunction and use of propranolol, in our circumstances.
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Affiliation(s)
- S Singhi
- Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India.
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27
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Affiliation(s)
- J J Farrar
- Wellcome Trust Clinical Research Unit, Centre for Tropical Diseases, Cho Quan Hospital, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam.
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Barennes H, Munjakazi J, Verdier F, Clavier F, Pussard E. An open randomized clinical study of intrarectal versus infused Quinimax for the treatment of childhood cerebral malaria in Niger. Trans R Soc Trop Med Hyg 1998; 92:437-40. [PMID: 9850403 DOI: 10.1016/s0035-9203(98)91083-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The intrarectal route has been shown to be an alternative to parenteral therapy for the treatment of acute uncomplicated malaria. We conducted an open randomized clinical study of intrarectal Quinimax (a Cinchona alkaloids association) (20 mg/kg, then 15 mg/kg every 8 h) vs. intravenous Quinimax (8 mg/ kg infused over 4 h every 8 h) for 2 d in 76 children (39 in the intrarectal and 37 in the infusion groups) with cerebral falciparum malaria in Niger. This treatment was followed by oral chloroquine (10 mg/kg/d for 3 d). The primary end points of the study were fatal outcome and coma recovery time. In the intrarectal group, 35 children were cured (90%) and 4 died. In the infused group, 28 were cured (76%) and 9 died; mean coma recovery times were 34.6 h (SD = 12.8) and 33.0 h (SD = 14.1) for the intrarectal and infused groups, respectively. None of the differences was significant. Both treatments were well tolerated and no anal irritation was observed with intrarectal Quinimax. These findings suggest that intrarectal Quinimax can be an alternative to intravenous administration for rapid onset childhood cerebral malaria in the rural tropics, where the safety of parenteral administration cannot be guaranteed.
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Affiliation(s)
- H Barennes
- Ministère de la Santé publique du Niger, Niamey, Niger
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Cao XT, Bethell DB, Pham TP, Ta TT, Tran TN, Nguyen TT, Pham TT, Nguyen TT, Day NP, White NJ. Comparison of artemisinin suppositories, intramuscular artesunate and intravenous quinine for the treatment of severe childhood malaria. Trans R Soc Trop Med Hyg 1997; 91:335-42. [PMID: 9231212 DOI: 10.1016/s0035-9203(97)90099-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Severe malaria remains a major cause of mortality and morbidity for children living in many tropical regions. With the emergence of strains of Plasmodium falciparum resistant to both chloroquine and quinine, alternative antimalarial agents are required. The artemisinin group of compounds are rapidly effective in severe disease when given by intramuscular or intravenous injection. However, these routes of administration are not always available in rural areas. In an open, randomized comparison 109 Vietnamese children, aged between 3 months and 14 years, with severe P.falciparum malaria, were allocated at random to receive artemisinin suppositories followed by mefloquine (n = 37), intramuscular artesunate followed by mefloquine (n = 37), or intravenous quinine followed by pyrimethamine/sulfadoxine (n = 35). There were 9 deaths: 2 artemisinin, 4 artesunate and 5 quinine-treated children. There was no difference in fever clearance time, coma recovery, or length of hospital stay among the 3 groups. However, parasite clearance times were significantly faster in artemisinin and artesunate-treated patients than in those who received quinine (P < 0.0001). Both artemisinin and artesunate were very well tolerated, but children receiving these drugs had lower peripheral reticulocyte counts by day 5 of treatment than those in the quinine group (P = 0.011). No other adverse effect or toxicity was found. There was no treatment failure in these 2 groups, but 4 patients in the quinine group failed to clear their parasites within 7 d of starting treatment and required alternative antimalarial therapy. Artemisinin suppositories are easy to administer, cheap, and very effective for treating children with severe malaria. In rural areas where medical facilities are lacking these drugs will allow antimalarial therapy to be instituted earlier in the course of the disease and may therefore save lives.
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Affiliation(s)
- X T Cao
- Dong Nai Paediatric Centre, Bien Hoa, Viet Nam
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Tran TH, Day NP, Nguyen HP, Nguyen TH, Tran TH, Pham PL, Dinh XS, Ly VC, Ha V, Waller D, Peto TE, White NJ. A controlled trial of artemether or quinine in Vietnamese adults with severe falciparum malaria. N Engl J Med 1996; 335:76-83. [PMID: 8649493 DOI: 10.1056/nejm199607113350202] [Citation(s) in RCA: 308] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Artemisinin (qinghaosu) and its derivatives are rapidly effective antimalarial drugs derived from a Chinese plant. Preliminary studies suggest that these drugs may be more effective than quinine in the treatment of severe malaria. We studied artemether in Vietnam, where Plasmodium falciparum has reduced sensitivity to quinine. METHODS We conducted a randomized, double-blind trial in 560 adults with severe falciparum malaria. Two hundred seventy-six received intramuscular quinine dihydrochloride (20 mg per kilogram of body weight followed by 10 mg per kilogram every eight hours), and 284 received intramuscular artemether (4 mg per kilogram followed by 2 mg per kilogram every eight hours). Both drugs were given for a minimum of 72 hours. RESULTS There were 36 deaths in the artemether group (13 percent) and 47 in the quinine group (17 percent; P = 0.16; relative risk of death in the patients given artemether, 0.74; 95 percent confidence interval, 0.5 to 1.11). The parasites were cleared more quickly from the blood in the artemether group (mean, 72 vs. 90 hours; P < 0.001); however, in this group fever resolved more slowly (127 vs. 90 hours, P < 0.001), the time to recovery from coma was longer (66 vs. 48 hours, P = 0.003), and the hospitalization was longer (288 vs. 240 hours, P = 0.005). Quinine treatment was associated with a higher risk of hypoglycemia (relative risk, 2.7; 95 percent confidence interval, 1.7 to 4.4; P < 0.001), but there were no other serious side effects in either group. CONCLUSIONS Artemether is a satisfactory alternative to quinine for the treatment of severe malaria in adults.
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Affiliation(s)
- T H Tran
- Wellcome Trust Clinical Research Unit, Center for Tropical Diseases, Ho Chi Minh City, Vietnam
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Barennes H, Kahiatani F, Pussard E, Clavier F, Meynard D, Njifountawouo S, Verdier F. Intrarectal Quinimax (an association of Cinchona alkaloids) for the treatment of Plasmodium falciparum malaria in children in Niger: efficacy and pharmacokinetics. Trans R Soc Trop Med Hyg 1995; 89:418-21. [PMID: 7570885 DOI: 10.1016/0035-9203(95)90036-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
In an attempt to avoid the complications associated with intramuscular quinine administration, we assessed the intrarectal route. Sixty-six children aged from 2 to 10 years with Plasmodium falciparum malaria were included in the study, which took place in Niamey, Niger. Fifty-five children were given 20 mg/kg of the diluted injectable form of Quinimax (a quinine, quinidine, cinchonine, cinchonidine association) intrarectally. A further 11 children with malaria were treated with 12.5 mg/kg of the same Quinimax solution by the intramuscular route. All the children were treated twice a day for 3 d. Blood samples were drawn from 20 children (15 treated intrarectally and 5 intramuscularly) for a kinetic study. Both modes of administration were well tolerated. Mean fever clearance times (+/- standard errors) were 48.6 +/- 2.7 h and 35.9 +/- 2.2 h in the intrarectal and intramuscular groups, respectively (P = 0.05). Mean parasite clearance times (+/- standard errors) and mean times to achieve 50% reduction in parasitaemia (+/- standard errors) were similar after intrarectal (46.5 +/- 5.7 h and 7.8 +/- 0.9 h respectively) and intramuscular administration (27.4 +/- 3.6 h and 8.7 +/- 1.7 h, respectively). Tmax. after intrarectal administration (2.7 +/- 0.4 h) did not differ significantly from the value after intramuscular administration (1.1 +/- 0.6 h), but Cmax. and the area under the concentration-time curve from 0 to 48 h were lower (4.9 +/- 0.6 mg/L and 230.0 +/- 9.6 mg/L.h, respectively) than after intramuscular administration (9.1 +/- 1.2 mg/L and 356.0 +/- 4.2 mg/L.h, respectively) (P < 0.001). Compared to the intramuscular route, intrarectal Quinimax bioavailability was 40%.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H Barennes
- Coopération Française, Ministère de la Santé Publique du Niger, Hôpital National de Niamey, Faculté des Sciences Médicales de Niamey
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