Comparison of artesunate and quinine in the treatment of severe Plasmodium falciparum malaria at Kassala hospital, Sudan.

INTRODUCTION: There is a need to investigate the treatment (artesunate and quinine) of severe malaria, as this will influence the outcome of morbidity and the mortality of the disease. METHODOLOGY: An open randomized trial conducted at Kassala, Sudan. Patients with severe P. falciparum malaria were randomly assigned to either intravenous artesunate at 2.4 mg/kg at 0, 12, and 24 hours, then daily, or intravenous quinine at a 20 mg/kg loading dose, then 10 mg/kg three times a day. Fever and parasite clearance and coma resolution time were compared between the two groups . RESULTS: The two groups (47 in each group) were well matched in the clinical and biochemical characteristics. Hypotension, convulsions, severe anemia, hypoglycemia, cerebral malaria, and jaundice were the predominant manifestations of severe malaria. The mean (SD) of the fever clearance (10.8 [5.5] vs. 14.0 [8.1] hours, p = 0.028) and the parasite clearance time (16.5 [6.4] vs. 21.7 [11.3] hours, p = 0.007) were significantly shorter in the artesunate-treated patients. In comatose patients, there was no difference between the two groups in coma resolution time. Following quinine infusion, ten patients developed tinnitus (p < 0.001), and four had hypoglycemia (p = 0.033). Tinnitus and hypoglycemia were not detected in the artesunate group. One patient in the artesunate group died. CONCLUSIONS: Artesunate is more effective than quinine, in term of parasite and fever clearance time, in the treatment of P. falciparum malaria in eastern Sudan. The study found no difference between artesunate and quinine in coma resolution time.

Liposomal amphotericin B for complicated visceral leishmaniasis (kala-azar) in eastern Sudan: how effective is treatment for this neglected disease?

OBJECTIVES: The aim of this study was to report the patient profile and treatment outcomes, including relapses, of patients with visceral leishmaniasis (VL) treated with liposomal amphotericin B (AmBisome) in Gedaref, Sudan. METHODS: AmBisome was offered to two groups of patients: primary VL patients with specific criteria (age ≤2 or ≥45 years, advanced clinical disease, pregnancy, HIV co-infection and contraindications for antimonials) and VL relapses. AmBisome was given at a total dose of 30 mg/kg, over 10 days. Slow responders received up to 50 mg/kg. Treatment failure was confirmed parasitologically. Standardised treatment outcomes were assessed. RESULTS: Between March 2010 and June 2012, a total of 281 (74%) patients with primary VL and 98 (26%) patients with VL relapses received AmBisome (54% male, median age = 11 years, interquartile range 2-30). End-of-treatment outcomes for primary VL were 260 (92%) initial cure including three (1%) slow responders, three (1%) treatment failures, 14 (5%) deaths and four (1%) unknown outcomes. Outcomes for VL relapses were 92 (94%) initial cure with five (5%) slow responders, four (4%) treatment failures, one (1%) death and one (1%) unknown outcome. At 6 months, there were 19 (7%) relapses amongst primary VL and 10 (10%) VL relapses had a new relapse. Loss to follow-up in both groups was 38%. None of the deaths that occurred during the study period was attributed to AmBisome. CONCLUSION: AmBisome appears to be effective for initial cure of VL and the drug seems safe, but is expensive (400 USD/treatment). Sustained mechanisms to allow improved access of this expensive drug particularly in East Africa are urgently needed. Relapses and losses to follow-up require specific investigation.