Efficacy and safety of exchange transfusion as an adjunct therapy for severe Plasmodium falciparum malaria in nonimmune travelers: A 10-year single-center experience with a standardized treatment protocol

Background: Even in circumstances where optimal antimalarial and supportive treatment is available, severe Plasmodium falciparum malaria is still associated with a significant case fatality. Although exchange transfusion (ET) has been considered as a controversial adjunct therapy, we have not encountered any case fatality since ET was introduced as a standard adjunct therapy for patients with severe malaria. Study design and methods: In this retrospective cohort study of 25 patients with severe malaria, the efficacy and safety of ET as an adjunct to parenteral antimalarial treatment (which was implemented in our hospital starting in 1998) were evaluated and compared with 31 historical control patients who were treated with conventional parenteral antimalarial treatment in the period before ET was added to the standard of care for severe malaria (generally before 1997). Results: The parasite clearance times (PCT)_25%, PCT_50%, PCT_75% and PCT_90% were all significantly shorter for patients treated with ET than for patients treated with parenteral quinine only. The shorter PCTs in the ET group were the result of a more rapid parasite clearance in the early phases after initiation of ET. Conclusion: No case fatalities were observed in the ET group. The complications that were observed with ET were more likely related either to the multiorgan dysfunction associated with severe malaria or to side effects of parenteral quinine rather than to the ET procedure. ET may be safely executed in a setting with intensive care facilities and availability of safe blood products and should be considered as a beneficial adjunct treatment to parenteral antimalarial therapy.