[Diluted injectable quinine in the intramuscular and intrarectal route: comparative efficacity and tolerance in malaria treatment for children ]

The intramuscular (i.m.) route is generally used for treatment of childhood falciparum malaria in outlying health care units in Togo. The purpose of this randomized therapeutic trial was to compare the efficacy and tolerance of diluted injectable quinine administered by the i.m. versus intrarectal (IR) route. A total of 64 children ranging in age from 8 months to 15 years were treated, i.e. 32 for each administration route. All children presented uncomplicated falciparum malaria in association with vomiting in 30 cases, a single unrecurring seizure with postictal coma lasting less than 30 minutes in 25 patients, or prostration without neurological manifestations in 9. Injectable quinimax (an association of cinchona alkaloids) was diluted to a concentration of 60 mg base/ml for i.m. injection into the thigh and 30 mg base/ml for use by the IR route. Administration was performed every 12 hours for 72 hours at a dose of 12.5 mg/kg for patients in the i.m. group or at a dose of 15 mg/kg in the IR group. The anus and lower rectal mucosa were examined using an anal valve before and after treatment using the IR route. Analysis of mean temperature curves demonstrated no significant difference between the clinical effectiveness of quinimax administered by the i.m. versus IR route (p > 0.05). Similar effect were also observed on parasitemia which disappeared completely in all patients by the end of the 72-hour treatment. The main problems were insufficient product retention requiring re-administration in 25% of patients in IR group and residual pain at the injection site in 12.5% of patients in the i.m. group. Endoscopic examination revealed no evidence of ulceration or necrosis of the anorectal mucosa. These findings indicate that administration of diluted injectable quinine by IR route is an effective, well-tolerated alternative for treatment of childhood falciparum malaria. It should be used preferentially in outlying health care units in patients presenting severe malaria pending transfer to an hospital, or signs of "intermediate severity" such as hyperpyrexia, hyperparasitemia, unrepeated seizure, or intensive vomiting.