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Malaria: an update on treatment of adults in non-endemic countries

BMJ 2006; 333 doi: (Published 27 July 2006) Cite this as: BMJ 2006;333:241

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An Italian experience with mefloquine

Dear Editor,
We read with great interest the essential facts on treating malaria for
patients in non-endemic countries by Christopher J M Whitty et al.(1)

We noticed that mefloquine, a milestone drug for uncomplicated
malaria treatment due to P. falciparum, was not even mentioned in this
review, and we were interested in understanding why this was excluded by
the authors.

The exclusion of mefloquine from malaria treatment is supported by
guidelines published by the WHO in 2006(2); it is considered a third- line
treatment option from the United States Centers for Disease Control and
Prevention, 2005 recommendations(3)

Few studies have compared anti-malarial drugs for uncomplicated
malaria treatment in returning travellers, and we believe that treatment
choices must consider both efficacy and tolerability(4.In non-endemic
areas,where vector transmission does not exist, single drug use should
have no impact in the selection of drug-resistance plasmodia.

The question of subjective tolerability to mefloquine is the
Achille's heel for this drug. A French study calculated a relative risk of
4.9 for discontinuation of treatment due to adverse events in a cohort of
65 uncomplicated malaria cases(5). In our clinical experience, the risk
for discontinuation of mefloquine treatment is very uncommon; this is
primarily due to the fact that the three doses of mefloquine are
administered in 6 hours intervals, and most side effects appears when
malaria treatment is already completed.

Between 2002-2006 at the Clinic of Infectious and Tropical Disease at
Modena University in northern Italy, 41 cases of uncomplicated malaria in
returning travellers were treated. In 37 cases, P.falciparum parasitemia
was detected by blood smear. Thirty-six patients had not received any
malarial prophylaxis, 4 patients did not complete the recommended
mefloquine prophylaxis treatment, and one patient reported adherence to
mefloquine prophylaxis.

(1)Christopher J M Whitty, david Lalloo, Andrew Ustianowski. Malaria: an
update on treatment of adults in non- endemic countries. BMJ 2006; 333;
(2)Guidelines for the tratment of malaria/WHO,2006; available at; accessed 20/08/2006
(3)Treatment of Malaria (Guidelines fot Clinicians) 2005; available at; accessed
(4)Mynt HY et al. A systematic overview of pubblished antimalarial drug
trials. Trans. R. Soc Trop Med Hyg 2004 feb; 98(2):73-81
(5)S.Rangue et al. Treatment of imported malaria in adults: a multicentre
study in France. Q J Med 2005; 98:737-743

Competing interests:
None declared

Competing interests: No competing interests

26 August 2006
Chiara Giovanardi
Francesca Sabbatini, Nicola Mongiardo, Giovanni Guaraldi, Roberto Esposito
Policlinico of Modena, via del Pozzo,41100 Modena, Italy