Intended for healthcare professionals

Rapid response to:

Practice BMJ Learning

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

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7561.241 (Published 27 July 2006) Cite this as: BMJ 2006;333:241

Rapid Response:

Outpatient Treatment of falciparum malaria in selected patients

In the recent article by Whitty et al (1) I was interested to read
that the authors advocate admitting patients to hospital for initial
treatment. Evidence from Europe (2) and St Thomas’ Hospital, London
(unpublished data) suggests that outpatient treatment with oral malarone
is safe in selected patients. Given the financial pressures of many NHS
trusts, the need to reduce length of inpatient stay and the patient’s
desirability to avoid hospital admission, clinical microbiologists and
infectious diseases physicians should consider outpatient treatment.

Since June 2003, at King George Hospital, BHR trust, 151 cases of
malaria have been diagnosed and managed without a single fatality. 124
(82.1%) were caused by P. falciparum and the majority of infections
occurred in Ghanians or Nigerians (85/124, 68.5%). With the exception of
fever most were well, despite being ‘semi-immune’ having lived in the UK
for many years. Doctors were encouraged to treatment patients with P.
falciparum infection out of hospital provided they are aged >16 years,
non-Causcaian, non-pregnant, clinically well (with the exception of
fever), able to tolerate the first dose of medication without vomiting,
had a parasitaemia <2% and normal renal function. More recently,
patients were followed up by telephone or seen in the outpatient clinic to
ensure compliance and a successful outcome.

Over a 3-year period, 95 patients were suitable for outpatient
treatment and 41 (43.2%) were managed successfully without the need for
hospital admission (4 by GP’s). Two patients with parasitaemia counts >
2% were treated as outpatients; one had refused hospital admission and
both survived. When admitted, average length of stay was 2.2 days. Errors
occurred more commonly in hospital and these included wrong treatment (eg.
oral chloroquine for P. falciparum), physicians withholding treatment
despite positive antigen tests and delays in administrating appropriate
antimalarials.

For adults in non-endemic countries, outpatient treatment of P.
falciparum malaria in selected patients is practicable and safe. However,
a prospective multi-centred randomised control study is required to
finally ‘put to bed’ the medical myth that all patients with falciparum
malaria require hospital admission.

References:

1 Whitty CJM, Lalloo D, Ustianowski A. Malaria: an update on
treatment of adults in non-endemic countries. BMJ 2006; 333:241-5.

2 D’Acremont V, Landry P, Dorioli R, Stuerchler D, Pecoud A and
Genton B. Treatment of imported malaria in an ambulatory setting:
prospective study. BMJ 2002; 321:875-6.

Mark Melzer MRCP, MRCPath, DTM&H
(Consultant Microbiologist with CCST in Infectious Diseases)

Competing interests:
None declared

Competing interests: No competing interests

05 August 2006
Mark Melzer
Consultant Microbiologist
King George Hospital, Barley Lane, Goodmayes, Essex IG3 8YB