UK malaria treatment guidelines
Section snippets
Background
Malaria remains one of the most common imported infections in the United Kingdom (UK). Between 1500 and 2000 malaria cases are reported each year in the UK, although informal reviews of reporting suggest that this may represent about half of all cases that occur (personal communication; P. Chiodini: Malaria Reference Laboratory). Approximately three-quarters of reported infections are due to Plasmodium falciparum and there were between 10 and 20 deaths annually. Children under 16 years account
History and examination
The crucial issue in the management of malaria is consideration of the possibility of this diagnosis. Malaria should be suspected in anyone with a fever or a history of fever who has returned from or previously visited a malaria-endemic area, regardless of whether they have taken prophylaxis. The minimum incubation period for naturally acquired infection is 6 days. Most patients with falciparum infection present in the first month or months after exposure; almost all present within 6 months of
Non-falciparum malaria
Malaria should always be managed in consultation with someone experienced in managing the disease.
The distinction between falciparum malaria and other species of malaria is important. Malaria caused by P. ovale, P. vivax and P. malariae rarely cause life-threatening disease, except in exceptional circumstances12 and can usually be managed on an outpatient basis, unless the patient has other co-morbidities. Estimation of the haemoglobin concentration should be done, and in malaria caused by
Treatment of uncomplicated falciparum malaria in adults
There are 3 main therapeutic options for the treatment of uncomplicated falciparum malaria in adults in the UK: oral quinine plus doxycycline (or quinine plus clindamycin in certain circumstances), co-artem (artemether–lumefantrine – Riamet®) or atovaquone–proguanil (Malarone®) (see Box 3 for details of doses). All are equally effective. Although mefloquine is effective, the side effects and high rate of non-completion of courses25 means that we do not recommend this as therapy in the UK.
Antimalarial therapy
Urgent appropriate therapy has the greatest impact on prognosis in severe malaria. Treatment should not be delayed in patients with proven or strongly suspected malaria. Parenteral treatment is indicated in all patients with severe or complicated malaria, those at high risk of developing severe disease (Box 4) or if the patient is vomiting and unable to take oral antimalarials.
Uncomplicated falciparum malaria in children
Oral quinine, atovaquone–proguanil (Malarone®) and co-artem (Riamet®) can all be used for the treatment of uncomplicated malaria in children (Table 1). In contrast to the views of some authors,43 we believe that oral quinine is usually well-tolerated by children and is an appropriate drug for the treatment of uncomplicated falciparum malaria in the UK.44 While there are concerns about increasing failure rates of anti-folate drugs, sulfadoxine–pyrimethamine (Fansidar®) still appears to be
Treating the acute infection
The treatment of non-falciparum malaria consists of treating the erythrocytic asexual forms that cause symptoms and, for infections with P. vivax and P. ovale, ensuring eradication of liver hypnozoites to prevent relapse of infection. If a mixed infection with falciparum has been treated, there is no need for an additional drug to treat the blood forms of non-falciparum infection, but relapse due to the liver forms will still need to be prevented. Chloroquine (20 mg/kg in total over 3 days) is
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