Лікування малярії в США

^a See table Drugs Used to Prevent Malaria for adverse reactions and contraindications. If malaria has developed during prophylactic drug therapy, that drug should not be used as part of the treatment regimen.

^b The pediatric dose should not exceed the adult dose.

^c Artemether/lumefantrine is available as a fixed-dose combination tablet of 20 mg/120 mg. Generally, this combination is not recommended for use in pregnant women, particularly during the 1st trimester, because safety data are insufficient; it may be used if other options are unavailable or are not tolerated and benefits outweigh risks. Patients should take the drug with food or whole milk. If patients vomit within 30 minutes of taking a dose, the dose should be repeated.

^d Atovaquone/proguanil is available as a fixed-dose combination tablet: adult tablets (250 mg atovaquone/100 mg proguanil) and pediatric tablets (62.5 mg atovaquone/25 mg proguanil). To enhance absorption, patients should take it with food or a milky drink. This combination is contraindicated in patients with creatinine clearance < 30 mL/min. Generally, this combination is not recommended for pregnant women, particularly during the 1st trimester, because safety data are insufficient; it may be used if other options are unavailable or are not tolerated and benefits outweigh risks. Twice a day dosing reduces nausea and vomiting as does taking it with food or milk. If patients vomit within 30 min of taking a dose, the dose should be repeated.

^e In the US, quinine sulfate capsules contain 324 mg, so 2 capsules are sufficient for adults. For children, dosing may be more difficult because noncapsule forms of quinine are not available. In Southeast Asia, relative resistance to quinine has increased, and treatment should be continued for 7 days. In other regions, treatment is continued for only 3 days. To reduce risk of gastrointestinal adverse effects, patients should take quinine with food. Quinine plus doxycycline or tetracycline is generally preferred to quinine plus clindamycin because there is more data on efficacy.

^f Use of tetracyclines is not recommended during pregnancy and in children < 8 years. However, doxycycline or tetracycline may be used if other treatment options are unavailable or not tolerated and if benefit is thought to outweigh risk.

^g Clindamycin is recommended to be used during pregnancy and in children < 8 years.

^h Mefloquine is not recommended unless other options cannot be used because the rate of severe neuropsychiatric reactions is higher with mefloquine than with other options. Mefloquine is contraindicated in patients who have active depression, a recent history of depression, generalized anxiety disorder, psychosis, schizophrenia, other major psychiatric disorders, or seizures. Mefloquine is not recommended for infections acquired in Southeast Asia because resistance to mefloquine has been reported in some areas (eg, the Myanmar borders with Thailand, China, and Laos; Thailand-Cambodia border; southern Vietnam).

ⁱ Any of the drug regimens recommended for P. falciparum malaria in chloroquine-resistant areas also can be used for any organism in chloroquine-sensitive areas; the fastest acting drug for falciparum malaria is artemeter-lumefantrine even if the infecting isolate is chloroquine-sensitive. For P. ovale or P. vivax infection, also give primaquine or tafenoquine (after testing to rule out G6PD deficiency).

^j To reduce risk of gastrointestinal effects, patients should take chloroquine with food.

^k Chloroquine or hydroxychloroquine is recommended for uncomplicated chloroquine-sensitive infections; however, regimens used to treat chloroquine-resistant infections may be used if they are more convenient or preferred or if chloroquine is unavailable.

^l Primaquine daily for 14 days or a single dose of tafenoquine is used to eradicate P. vivax and P. ovale hypnozoites that may remain dormant in the liver and thus prevent relapses of these infections. Because primaquine and tafenoquine can cause hemolytic anemia in patients with G6PD deficiency, G6PD screening must be done before starting treatment with them. For patients with borderline G6PD deficiency or as an alternate to the above regimen, primaquine 45 mg orally once a week may be given for 8 weeks; clinicians should consult with an expert in infectious disease and/or tropical medicine if this alternative regimen is being considered for G6PD-deficient patients. Primaquine and tafenoquine should not be used during pregnancy, or during breast feeding unless the newborn is tested and has a normal G6PD level.

^m If patients acquire P. vivax infection in regions not known to harbor chloroquine-resistant P. vivax infection, treatment should start with chloroquine. If they do not respond, treatment should be changed to a chloroquine-resistant P. vivax regimen, and clinicians should call the CDC Malaria Hotline.

ⁿ The CDC recommends that patients with severe malaria be treated with parenteral (IV) artesunate as soon as possible. IV quinidine is no longer available in the US. Malaria is considered to be severe when patients have ≥ 1 of the following: impaired consciousness, coma or seizure, severe normocyctic anemia (hemoglobin < 7 g/dL [70 g/L]), renal failure, pulmonary edema, acute respiratory distress syndrome, shock, disseminated intravascular coagulation, spontaneous bleeding, acidosis, hemoglobinuria, jaundice, or parasitemia > 5%. Severe malaria is most often caused by P. falciparum. Artesunate IV also is recommended for patients who cannot take medications orally.

In the US, IV artesunate received US Food and Drug Administration approval in May 2020. If it cannot be obtained quickly from a commercial source, it is available during an interim period from the CDC by calling the CDC Malaria Hotline. It is estimated that it may take 12-24 hours for artesunate to reach hospitals in the US.

When IV artesunate is not immediately available, start interim oral therapy with artemether-lumefantrine, atovaquone-proguanil, quinine sulfate or if nothing else is available, mefloquine. In patients who are vomiting, an antiemetic may be helpful. Those who cannot swallow may be given crushed tablets of artemether/lumefantrine or atovaquone/proguanil through a nasogastric tube.

^o The CDC Malaria Hotline is available at 770-488-7788 or 855-856-4713 toll-free Monday-Friday 9AM to 5PM EST (after hours, weekends, or holidays, 770-488-7100).

^p If patients cannot take oral clindamycin, a loading dose of 10 mg/kg is given IV, followed by 5 mg/kg every 8 hours, then switched to oral administration as soon as patients are able. Rapid IV administration should be avoided. Treatment course is 7 days.

G6PD = glucose-6-phosphate dehydrogenase; CDC = Centers for Disease Control and Prevention

Adapted from the CDC: Malaria diagnosis and treatment in the United States.