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Artemisinin is the frontline fast-acting anti-malarial against  P. falciparum . Emergence and spread of resistant parasite in eastern-India poses a threat to national malaria control programs. Therefore, the objective of our study is to evaluate the artesunate-sulfadoxine-pyrimethamine efficacy in Central India. 180 monoclonal  P. falciparum -infected patients received standard ASSP therapy during August 2015–January 2017, soon after diagnosis and monitored over next 42-days. Artemisinin-resistance was assessed through in-vivo parasite clearance half-life (PC 1/2 ), ex-vivo ring-stage survivability (RSA), and genome analysis of  kelch13  and other candidate gene ( pfcrt, pfmdr1, pfatpase 6, pfdhfr  and  pfdhps ). Of 180  P. falciparum  positive patients, 9.5% showed increased PC 1/2  (> 5.5 h), among them eleven isolates (6.1%) showed reduced sensitivity to RSA. In 4.4% of cases, parasites were not cleared by 72 h and showed prolonged PC 1/2 (5.6 h) (P < 0.005) along with significantly higher RSA (2.2%) than cured patients (0.4%). None of day-3 positive isolates contained the  pfkelch13  mutation implicated in artemisinin resistance. Parasite recrudescence was observed in 5.6% patients, which was associated with triple  dhfr – dhps  (A 16  I  51  R  59  N  108 I 164 –S 436  G  437 K 540  G   581   T   613  ) combination mutation. Emergence of reduced sensitivity to artesunate-sulfadoxine-pyrimethamine, in central India highlighted the risk toward spread of resistant parasite across different parts of India. Day-3 positive parasite, featuring the phenotype of artemisinin-resistance without  pfkelch13  mutation, suggested  kelch13 -independent artemisinin-resistance.

Artemisinin combination therapy fails even in the absence of Plasmodium falciparum kelch13 gene polymorphism in Central India