Abstract
In this position paper, the European Society for Clinical Microbiology and Infectious Diseases, Study Group on Clinical Parasitology, summarizes main issues regarding the management of imported malaria cases. Malaria is a rare diagnosis in Europe, but it is a medical emergency. A travel history is the key to suspecting malaria and is mandatory in patients with fever. There are no specific clinical signs or symptoms of malaria although fever is seen in almost all non-immune patients. Migrants from malaria endemic areas may have few symptoms.Malaria diagnostics should be performed immediately on suspicion of malaria and the gold- standard is microscopy of Giemsa-stained thick and thin blood films. A Rapid Diagnostic Test (RDT) may be used as an initial screening tool, but does not replace urgent microscopy which should be done in parallel. Delays in microscopy, however, should not lead to delayed initiation of appropriate treatment. Patients diagnosed with malaria should usually be hospitalized. If outpatient management is preferred, as is the practice in some European centres, patients must usually be followed closely (at least daily) until clinical and parasitological cure. Treatment of uncomplicated Plasmodium falciparum malaria is either with oral artemisinin combination therapy (ACT) or with the combination atovaquone/proguanil. Two forms of ACT are available in Europe: artemether/lumefantrine and dihydroartemisinin/piperaquine. ACT is also effective against Plasmodium vivax, Plasmodium ovale, Plasmodium malariae and Plasmodium knowlesi, but these species can be treated with chloroquine. Treatment of persistent liver forms in P. vivax and P. ovale with primaquine is indicated after excluding glucose 6 phosphate dehydrogenase deficiency. There are modified schedules and drug options for the treatment of malaria in special patient groups, such as children and pregnant women. The potential for drug interactions and the role of food in the absorption of anti-malarials are important considerations in the choice of treatment.Complicated malaria is treated with intravenous artesunate resulting in a much more rapid decrease in parasite density compared to quinine. Patients treated with intravenous artesunate should be closely monitored for haemolysis for four weeks after treatment. There is a concern in some countries about the lack of artesunate produced according to Good Manufacturing Practice (GMP).
Highlights
Malaria continues to pose challenges in diagnosis and management and remains an infrequently encountered infection for many physicians in non-endemic areas
The use of chloroquine is not recommended for the treatment of P. falciparum malaria because of widespread resistance
If Rapid Diagnostic Test (RDT) indicate the diagnosis of malaria but microscopy cannot be performed adequate treatment should be started straight away and the patient promptly transferred to a health care facility where microscopy can be done
Summary
Malaria continues to pose challenges in diagnosis and management and remains an infrequently encountered infection for many physicians in non-endemic areas. Automated red blood cell exchange (i.e. erythrocytopheresis) is another potentially useful adjunctive treatment option to rapidly reduce high parasitaemia by removing infected erythrocytes It has the advantage of less interference with volume and electrolyte status of the patient, but no randomized controlled trial has been conducted so far [100,101] and its role is unclear since the advent of ACT. The clinical approach to the treatment of children is comparable to adult patients and relies on the classification into uncomplicated and severe falciparum malaria (Table 2). In line with recommendations for adults, ACT and atovaquone-proguanil are the recommended first-line treatments for uncomplicated P. falciparum malaria in paediatric patients in Europe (Table 5). Anti-malarial treatment of severe malaria in children follows similar algorithms as for adult patients and is based on prompt administration of intravenous artesunate (or quinine if artesunate is not available). Patients receiving intravenous artesunate should be monitored twice weekly for 4 weeks following IVA for hemolysis and leucopenia
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