Intrarectal quinine for treating Plasmodium falciparum malaria

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.

To compare intrarectal quinine with intravenous or intramuscular quinine for treating malaria caused by Plasmodium falciparum.

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.

Randomized and quasi-randomized controlled trials comparing intrarectal quinine with intramuscular and intravenous quinine for treating people with uncomplicated and severe falciparum malaria.

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.

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.

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.