Outcome evaluation

When advising potential travelers on prophylaxis for malaria, be aware of the incidence of chloroquine-resistant P. falciparum malaria and the countries where it is prevalent.60-74 In patients who have P vivax or P ovale malaria (note that some patients can have P falciparum and one of these species), following the treatment of the acute phase of malaria and screening for glucose-6-phosphate dehydrogenase deficiency, patients should receive a regimen of primaquine for 14 days to ensure eradication of the hypnozoite stage of P vivax or P ovale.63 For detailed recommendations for prevention of malaria go to www.cdc.gov/travel/.

Patient Encounter 3, Part 3: Malaria

Following treatment of falciparum malaria, TW has remained well for 2 months. However, 2 days ago, he started developing fever and chills, nausea, and abdominal pain. When seen in the emergency department he has a fever of 38.4°C (101.1°F) and complains of severe headache. Examinations of a thick and thin blood smear of the patient's blood identified P. vivax infection. TW received a course of chloroquine and primaquine. In a follow-up 2 weeks later, a repeat blood smear was negative for parasites and the patient was asymptomatic.

Patient Care and Monitoring: Malaria

• Acute P. falciparum malaria resistant to chloroquine should be treated with IV quin-idine via central venous catheter and fluid status and the electrocardiogram (ECG) should be monitored closely.

• The loading dose of quinidine should be omitted in those patients who have received quinine or mefloquine.

• Hypoglycemia that is associated with both P falciparum and quinidine administration, should be checked every 4 to 6 hours and corrected with dextrose infusions (5-10%).

• Quinidine infusions should be slowed temporarily or stopped if the QT interval is greater than 0.6 second, the increase in the QRS complex is greater than 25%, or hypotension unresponsive to fluid challenge results.

• The suggested quinidine levels should be maintained at 3 to 7 mg/dL (9.2-21.6 ^mol/L).

• Blood smears should be checked every 12 hours until parasitemia is less than 1%.

• Resolution of fever should take place between 36 and 48 hours after initiation of the IV quinidine therapy, and the blood should be clear of parasites in 5 days.

• When parenteral therapy is required for more than 48 hours or the patient's renal function deteriorates, the dose of quinidine should be lowered by half.

Advice to Travelers

All travelers to endemic areas should be advised to remain in well-screened areas, to wear clothes that cover most of the body, and sleep in mosquito nets. Travelers should adhere to malaria chemoprophylaxis regimens and carry the insect repellant DEET (N, N-diethylmetatoluamide) or other insect sprays containing DEET for use in mosquito-infested areas.

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