correspondence

Evidence of Artemisinin-Resistant Malaria

in Western Cambodia
To the Editor: Although artemisinins are potent and rapidly acting antimalarial drugs, their
widespread use for treating patients with Plasmodium falciparum malaria raises the question of
emerging drug resistance.1,2 Artemisinin monotherapy should not be used in areas where malaria is endemic; it requires an extended administration period and may lead to treatment failure,
most frequently because of problems with compliance. Recent reports of high failure rates associated with artemisinin-based combination therapy, as well as in vitro drug-susceptibility data,
suggest the possibility of clinical artemisinin resistance along the ThaiCambodian border.3,4
We studied the potential emergence of artemisinin resistance using in vivo, in vitro, molecular,
and pharmacokinetic methods specifically designed to address the question of potential artemisinin resistance.
We randomly assigned, in a ratio of 2:1, 94
adults from Battambang Province presenting with
uncomplicated P. falciparum malaria (100 to 100,000
parasites per microliter) to receive either highdose artesunate therapy (4 mg per kilogram of
body weight per day, orally, for 7 days) (60 pa-

tients) or quinine (30 mg per kilogram per day)

plus tetracycline (25 mg per kilogram per day) in
a split dose every 8 hours for 7 days (34 patients).
The study was approved by ethics review committees in Cambodia and the United States and
was conducted from October 2006 through March
2007. Written informed consent was obtained
from all study participants.
Patients were admitted for 28 days to rule out
reinfection. The clinical outcome was recorded,
plasma drug concentrations and in vitro drug
susceptibility were measured, and molecular assays were performed to investigate genetic resistance markers and to rule out reinfection. Only
patients who met all the following criteria were
classified as having artemisinin-resistant infection: persistence of parasites 7 days after the start
of treatment or reemergence of parasites within
28 days after the start of treatment; adequate
plasma concentrations of dihydroartemisinin, a
major artemisinin metabolite; prolonged time to
parasite clearance; and reduced in vitro susceptibility to dihydroartemisinin.5
Four of the 60 patients who received artesunate had reemergence of parasitemia between
B

100
Treatment failure due
to drug failure

Parasite Density
(% of density at screening)

90
80
70

Treatment failure due

to artemisinin resistance

60

Cure

50
40
30
20
10
0

24

48

72

96

120

Log10 Dihydroartemisinin IC50 (nM)

100.0

10.0

1.0
P=0.03
0.1

Hours after First Dose of Artesunate

20

40

60

80

100

120

140

Parasite-Clearance Time (hr)

Figure 1. Parasite Density, Parasite-Clearance Time, and 50% Inhibitory Concentration (IC50) among Patients Receiving Artesunate,
ccording to Clinical Outcome.
A
RETAKE
1st classified as having artemisinin-resistant
Panel A shows the parasite-reduction curvesICM
for theAUTHOR:
56 patients
who were cured, the
2 patients
Noedl
2ndclassified as having artemisinin-resistant
infections, and the 2 with drug failures (i.e., patients
who had recrudescence but who were not
REG F FIGURE: 1 of 1
3rd
infection, since the drug level was inadequate).
The
data
points
and
horizontal
I
bars
denote
the means and standard errors. Panel B
CASE
Revised
shows the parasite-clearance times in the artesunate
group,
as
compared
with
the
IC
for
dihydroartemisinin
(R=0.31, P=0.03). Orange
Line
4-C
50 SIZE
EMail
ARTIST:
ts
circles indicate patients whose infection was classified
as artemisinin-resistant,
squares patients in whom treatment failed but
H/T
H/Tand blue36p6
Enon
Combo
whose infection was not classified as resistant.
AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.
Please check carefully.

n engl j medJOB:
359;24
2008 12-11-08
35924www.nejm.org december 11, ISSUE:

The New England Journal of Medicine

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2619

correspondence

days 21 and 28 after the start of treatment (with

a KaplanMeier probability estimate for cure at
day 28 of 93.6%; 95% confidence interval [CI], 84.7
to 97.7); 2 of these patients (3.3%) were classified as having artemisinin-resistant infection,
according to the criteria listed above (Fig. 1A).
These two patients had parasite-clearance times
that were prolonged (133 and 95 hours, as compared with a median of 52.2 hours for patients
who were cured), and the plasma drug concentrations after the first dose were classified as
adequate (greater than the mean for the cured
patients minus 1 SD) (see the Supplementary Appendix, available with the full text of this letter
at www.nejm.org). For these subjects, the 50%
inhibitory concentrations for dihydroartemisinin
were up to 4 times the geometric mean for cured
patients and almost 10 times that for the reference clone W2. In the artesunate group, 47.9%
(95% CI, 36.1 to 60.0) of the patients still had
parasitemia 48 hours after the start of treatment, as did 21.9% (95% CI, 13.1 to 33.1) 72
hours after the start of treatment. Clinical and
in vitro data suggest that artemisinin resistance
may be more accurately portrayed as the long tail
of a single distribution than as the result of a
sudden change in sensitivity (Fig. 1B). Resistance
did not appear to be mediated by the number of
copies of the P. falciparum multidrug resistance
gene pfmdr1 or selected PfATPase6 polymorphisms
tested in this study.
The high overall treatment efficacy seen in patients treated with artesunate indicates that relatively few parasite isolates have crossed the threshold of artemisinin resistance as defined in our
study. Artemisinin resistance does not seem to be
a widespread epidemiologic phenomenon at this

time. The prolonged parasite-clearance times and

the two cases meeting our definition of artesunate resistance are nonetheless a concern.
Harald Noedl, M.D., Ph.D.
Medical University of Vienna
A-1090 Vienna, Austria
harald.noedl@meduniwien.ac.at

Youry Se, M.D.

Kurt Schaecher, Ph.D.
Bryan L. Smith, M.D.
Armed Forces Research Institute of Medical Sciences
Bangkok 10400, Thailand

Duong Socheat, M.D.

National Center for Parasitology, Entomology, and Malaria Control
Phnom Penh, Cambodia

Mark M. Fukuda, M.D.

Armed Forces Research Institute of Medical Sciences
Bangkok 10400, Thailand

for the Artemisinin Resistance in Cambodia 1

(ARC1) Study Consortium
Supported by the U.S. Department of Defense Global Emerging Infections System Program. The opinions or assertions contained herein are the private views of the authors and are not to
be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
1. Duffy PE, Sibley CH. Are we losing artemisinin combination

therapy already? Lancet 2005;366:1908-9.

2. Krishna S, Bustamante L, Haynes RK, Staines HM. Artemisinins: their growing importance in medicine. Trends Pharmacol
Sci 2008;29:520-7.
3. Jambou R, Legrand E, Niang M, et al. Resistance of Plasmodium falciparum field isolates to in-vitro artemether and point
mutations of the SERCA-type PfATPase6. Lancet 2005;366:
1960-3.
4. Vijaykadga S, Rojanawatsirivej C, Cholpol S, Phoungmanee
D, Nakavej A, Wongsrichanalai C. In vivo sensitivity monitoring
of mefloquine monotherapy and artesunate-mefloquine combinations for the treatment of uncomplicated falciparum malaria
in Thailand in 2003. Trop Med Int Health 2006;11:211-9.
5. Noedl H. Artemisinin resistance: how can we find it? Trends
Parasitol 2005;21:404-5.
Correspondence Copyright 2008 Massachusetts Medical Society.

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n engl j med 359;24 www.nejm.org december 11, 2008

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