Version May 2024
| Drug | Adult dose | Pediatric dose (not to exceed adult dose) |
| Preferred regimen in all regions for uncomplicated P. falciparum[1] | ||
| Artemisinin combination therapy | Regimens and doses summarized in separate UpToDate table. | Regimens and doses summarized in separate UpToDate table. |
| Alternative regimens for chloroquine-resistant malaria¶ | ||
| Atovaquone-proguanilΔ Adult tab = 250 mg atovaquone/100 mg proguanil Pediatric tab = 62.5 mg atovaquone/25 mg proguanil | 4 adult tabs orally once daily for 3 days | 5 to <8 kg: 2 pediatric tabs orally once daily for 3 days 8 to <10 kg: 3 pediatric tabs orally once daily for 3 days 10 to <20 kg: 1 adult tab orally once daily for 3 days 20 to <30 kg: 2 adult tabs orally once daily for 3 days 30 to <40 kg: 3 adult tabs orally once daily for 3 days ≥40 kg: 4 adult tabs orally once daily for 3 days |
Quinine sulfate◊ PLUS one of the following:
| United States: Quinine sulfate 648 mg salt◊ (= 538 mg base) orally three times daily for three or seven days¥ Canada, European Union, United Kingdom: Quinine sulfate 600 mg salt◊ (= 500 mg base) orally 3 times daily for 3 or 7 days¥ | Quinine sulfate◊: 10 mg salt/kg (= 8.3 mg base/kg) orally 3 times daily for 3 or 7 days¥ |
| plus one of the following: | plus one of the following: | |
| Doxycycline: 100 mg orally twice daily for 7 days | Doxycycline:§ 2.2 mg/kg orally twice daily for 7 days | |
| Tetracycline: 250 mg orally 4 times daily for 7 days | Tetracycline:§ 6.25 mg/kg orally 4 times daily for 7 days | |
| Clindamycin: 20 mg/kg/day (up to 1.8 g) orally divided 3 times daily for 7 days | Clindamycin: 20 mg/kg/day (up to 1.8 g) orally divided 3 times daily for 7 days | |
| Mefloquine‡ | 500 mg salt (= 456 mg base) orally once daily for 3 days or 8 mg salt/kg (= 7.3 mg base/kg) orally once daily for 3 days, whichever is less (Total maximum dose: 1500 mg salt [= 1369 mg base] in equally divided doses over 3 days) | 8 mg salt/kg (= 7.3 mg base/kg) orally once daily for 3 days; maximum 500 mg salt (= 456 mg base) per dose (Total dose: 24 mg salt/kg (= 22 mg base/kg); maximum 1500 mg salt [= 1369 mg base] in equally divided doses over 3 days) |
| Alternative regimens for chloroquine-sensitive malaria† | ||
| Central America west of Panama Canal; Haiti; the Dominican Republic; and most of the Middle East. Infections acquired in North and South Korea and the states of the former Soviet Union have been uniformly caused by Plasmodium vivax to date and should therefore be treated as chloroquine-sensitive infections. | ||
| Chloroquine** | Dose 1: 1000 mg salt (= 600 mg base) orally Doses 2 to 4 (3 additional doses) at 6, 24, and 48 hours: 500 mg salt (= 300 mg base) orally per dose (Total dose: 2500 mg salt [= 1500 mg base]) | Dose 1: 16.7 mg salt/kg (10 mg base/kg) orally Doses 2 to 4 (3 additional doses) at 6, 24, and 48 hours: 8.3 mg salt/kg (5 mg base/kg) orally per dose (Total dose: 41.6 mg salt/kg [25 mg base/kg]; maximum total dose 2500 mg salt [= 1500 mg base]) |
| or | ||
| Hydroxychloroquine** | Dose 1: 800 mg salt (= 620 mg base) orally Doses 2 to 4 (3 additional doses) at 6, 24, and 48 hours: 400 mg salt (= 310 mg base) orally per dose (Total dose: 2000 mg salt [= 1550 mg base]) | Dose 1: 12.9 mg salt/kg orally (10 mg base/kg) Doses 2 to 4 (3 additional doses) at 6, 24, and 48 hours: 6.5 mg salt/kg (5 mg base/kg) orally per dose (Total dose: 32.4 mg salt/kg [ = 25 mg base/kg]; maximum total dose 2000 mg salt [= 1550 mg base]) |
The dosing regimens listed in this table are generally consistent with CDC guidelines for the treatment of uncomplicated malaria in the United States and may differ from dosing recommended in approved product information.
The WHO recommends ACT as first-line treatment for uncomplicated malaria. The CDC prefers ACT (artemether-lumefantrine); it states atovaquone-proguanil and quinine combination therapy are adequate alternatives if more readily available and that mefloquine should be used only if other options are not available. Because there are more data on the efficacy of quinine in combination with doxycycline or tetracycline, these treatment combinations are generally preferred over quinine in combination with clindamycin. In addition, quinine combination therapy has higher incidence of adverse effects than ACT or atovaquone-proguanil. Because mefloquine is associated with severe neuropsychiatric reactions, this regimen is recommended only when other options cannot be used.CDC: United States Centers for Disease Control and Prevention; WHO: World Health Organization; ACT: artemisinin combination therapy.
* If an antimalarial agent was taken for chemoprophylaxis, a different drug should be used for treatment.
¶ In the setting of exposure to a region with unknown prevalence of chloroquine resistance or uncertain exposure history, treatment for chloroquine-resistant P. falciparum should be administered.
Δ Take with food or whole milk. If patient vomits within 30 minutes of taking a dose, then they should repeat the dose. It is also acceptable to take one-half of the dose twice daily.
◊ In the United States and Canada, pill strengths for quinine are labeled as quinine sulfate (salt); in many other countries, pill strengths are labeled in quinine base. 324 mg quinine sulfate (salt) = 269 mg quinine base. Pediatric dosing may require compounding pharmacy, since noncapsule forms of quinine are not available in the United States.
§ For children less than 8 years old with chloroquine-resistant P. falciparum, atovaquone-proguanil and artemether-lumefantrine are recommended treatment options. Tetracycline antibiotics may cause permanent tooth discoloration for children <8 years if used repeatedly. However, doxycycline binds less readily to calcium than other tetracyclines and may be used for ≤21 days in children of all ages.[2] Mefloquine can be considered for treatment of malaria in children if no other options are available.
¥ For infections acquired in Southeast Asia, quinine treatment should continue for 7 days. For infections acquired elsewhere, quinine treatment should continue for 3 days.
‡ Mefloquine should be used only if other options are not available, and it is not recommended for children <15 kg or in patients with neuropsychiatric history. In addition, treatment with mefloquine is not recommended for patients who have acquired infection from Southeast Asia, due to drug resistance. The dosing regimen for mefloquine above is in alignment with the WHO[3], which differs from the CDC approach; the WHO approach is associated with greater bioavailability and is better tolerated[4]. In the United States and Canada, pill strengths for mefloquine are labeled in hydrochloride salt; in many other countries, pill strengths are labeled in mefloquine base. 250 mg mefloquine hydrochloride (salt) is equivalent to 228 mg mefloquine base.
† For patients with chloroquine-sensitive malaria who cannot be treated with ACT, chloroquine or hydroxychloroquine may be used. The alternative agents for chloroquine-resistant malaria are also acceptable in such cases.
** In the United States and Canada, pill strengths for chloroquine and hydroxychloroquine are labeled in salt; in many other countries, pill strengths are labeled in base. 250 mg chloroquine phosphate (salt) is equivalent to 150 mg chloroquine base; 200 mg hydroxychloroquine sulfate (salt) is equivalent to 155 mg hydroxychloroquine base.Adapted from United States Centers for Disease Control and Prevention. Guidelines for Treatment of Malaria in the United States: https://www.cdc.gov/malaria/resources/pdf/Malaria_Treatment_Table.pdf (Accessed on September 15, 2022.) CDC Malaria Hotline: (770) 488-7788 Monday to Friday 9:00 am to 5:00 pm EST; (770) 488-7100 after hours, weekends, and holiday and ask to speak to CDC Malaria Branch clinician on call.
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