Outpatient treatment of falciparum malaria is possible

Editor—Whitty et al advocate admitting patients to hospital for initial treatment of malaria.¹ Evidence from Europe and St Thomas' Hospital, London (unpublished data) show that outpatient treatment with oral atovaquone and proguanil (Malarone) is safe in selected patients.² Given the financial pressures of many NHS trusts, the need to reduce length of inpatient stay, and patients' wish to avoid hospital admission, clinical microbiologists and infectious disease doctors should consider outpatient treatment.

Since June 2003, 151 cases of malaria have been diagnosed and managed without a single fatality at this hospital. Of these, 124 (82%) were caused by Plasmodium falciparum, most infections occurring in people from Ghana or Nigeria (85/124, 68.5%). With the exception of fever, most were well, despite being “semi-immune,” having lived in the United Kingdom for many years. Doctors were encouraged to treat patients with P falciparum infection out of hospital, provided that patients were aged 16 or older, were not of white ethnic group, were not pregnant, were clinically well (with the exception of fever), could tolerate the first dose of drugs without vomiting, had a parasitaemia rate of less than 2%, and had 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 three years 95 patients were suitable for outpatient treatment and 41 were managed successfully without the need for hospital admission (four by general practitioners). Two patients with parasitaemia counts of more than 2% were treated as outpatients; one had refused hospital admission, and both survived. When admitted, the average length of stay was 2.2 days. Errors occurred more commonly in hospital, including wrong treatment (for example, oral chloroquine for P falciparum), doctors withholding treatment despite positive antigen tests, and delays in administrating appropriate antimalarial drugs.

For adults in non-endemic countries, outpatient treatment of P falciparum malaria in selected patients is practicable and safe. However, a prospective multicentre randomised controlled study is required to finally abolish the medical myth that all patients with falciparum malaria require admission to hospital.