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The Journal of the Royal Institute of Thailand Volume II - 2010 Prakaykaew Charunwatthana, Sasithon 105 Quinine-tetracycline/Quinine-clindamycin Quinine in combination with tetracycline has been widely used for nearly 20 years in multi-drug resistant areas. In Thailand, the cure rate of monotherapy with quinine given for 7 days was 100% in 1963. Since the 1970s there has been a decline in the susceptibility to quinine but this has been relatively slow (Figure 2). The addition of a tetracycline, most commonly, doxycycline, to quinine consistently improves the cure rates for falciparum malaria to over 90%. A limitation of this combination is that tetracycline cannot be used in children less than 8 years old or during pregnancy. Quinine-clindamycin has proved effective in adults and children with acute malaria in South America, Africa and in Thailand where the most drug- resistant P. falciparum strains are found (Pukrittayakamee et al, 2000, Figure 4). The regimen was well tolerated, and there were no adverse effects attributable to clindamycin. WHO Recommendations on malaria treatment (WHO, 2010) WHO Guidelines Development Group recommends that all countries experiencing resistance to conventional monotherapies, such as chloroquine, amodiaquine or sulfadoxine–pyrimethamine, should use combination therapies, preferably those containing artemisinin derivatives for falciparum malaria. The ACT Figure 4 Cumulative cure rates for quinine and quinine in combination with tetracycline or clindamycin in patients with uncomplicated P.falciparum malaria. (adapted from Pukrittayakamee et al, 2000).