Panel’s Recommendations

Families traveling to malaria-endemic countries should receive pre-travel counseling, including information on insecticide-treated bed nets, N,N-Diethyl-meta-toluamide, and country-specific antimalarial prophylaxis (AII). Trimethoprim-sulfamethoxazole is not recommended for antimalarial prophylaxis (AIII). Treatment of malaria is based on disease severity, patient age, parasite species, pregnancy status, and local resistance patterns where the malaria infection was acquired (AI). The choice of malaria therapy is not affected by HIV status but can be modified based on potential interactions between antiretroviral and antimalarial drugs (AIII). Quinidine is not recommended for patients who are taking ritonavir (AIII) (ritonavir may be replaced if quinidine is needed for severe malaria) and should be administered with caution with atazanavir, darunavir and fosamprenavir (AIII). The treatment options for uncomplicated chloroquine-susceptible Plasmodium falciparum malaria include chloroquine phosphate, atovaquone-proguanil, artemether-lumefantrine, and quinine sulfate plus either doxycycline, tetracycline (in children aged ≥8 years), or clindamycin. Mefloquine is considered an alternative regimen (AIII). Chloroquine should not be used to treat malaria infections acquired in areas with chloroquine resistance (AIII). Treatment of uncomplicated chloroquine-resistant malaria may include atovaquone-proguanil, quinine sulfate plus either doxycycline or tetracycline (specifically in children aged ≥8 years) or clindamycin or artemether-lumefantrine (AIII). Treat for presumptive chloroquine-resistant P. falciparum malaria in symptomatic patients who have traveled to a region with chloroquine-resistant P. falciparum and for whom reliable identification of the malaria species is not possible or who are severely ill (AIII). After initial treatment for Plasmodium vivax and Plasmodium ovale (same as for uncomplicated P. falciparum), primaquine is recommended for treatment of the dormant liver stage (hypnozoites) (AIII). Glucose-6-phosphate dehydrogenase deficiency must be excluded before use of primaquine because of risk of severe hemolytic anemia (AIII). Treatment of severe malaria includes both IV quinidine gluconate plus either doxycycline OR clindamycin OR tetracycline. Alternatives include artesunate IV (under Investigational New Drug protocol: Contact the Centers for Disease Control and Prevention Malaria Hotline at (770) 488-7788) followed by either doxycycline OR atovaquone-proguanil OR mefloquine OR clindamycin (AIII).

Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials in children^† with clinical outcomes and/or validated endpoints; I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children^† from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children^† with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children^† from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = Expert opinion

^†Studies that include children or children/adolescents, but not studies limited to post-pubertal adolescents.