Rationale:

• Infectious diseases specialists may be able to identify local physicians with experience in treating malaria, expedite the processing and expert reading of blood smears, facilitate the acquisition of quinidine (the only parenteral drug available in the U.S. for the treatment of severe malaria), evaluate for concomitant bacterial infections, and generate differential diagnoses of tropical diseases that are life-threatening and require specific antibiotic therapy.
• Pharmacy services may not have quinidine in stock and may need to contact local or regional suppliers to locate and deliver the drug.
• QT prolongation occurs with administration of quinidine.
• Electrolyte disturbances and volume overload that result from renal failure may require dialysis to correct.

Evidence:

• The case fatality rates associated with P. falciparum malaria “imported” into the U.S. and with severe malaria, even when managed in ICU settings, was found to be 3.8% (24) and >20%, respectively. In one retrospective study of 93 patients with severe malaria admitted to an ICU in France, 11% died (151).
• Delays in the recognition and treatment of malaria are associated with increases in morbidity and mortality. For example, one case series showed that malaria was not considered as an initial diagnosis in 25 of 59 patients presenting with malaria in Houston, Texas. Five of these patients presented with severe disease, 4 of whom had initially received a misdiagnosis (152).
• In one series of fatal P. falciparum malaria reported in the U.S., 40% of patients were not recognized as having malaria during their initial encounter with a physician (24).
• Patients who present to clinics that do not have expertise in tropical medicine are likely to receive suboptimal treatment. For example, one prospective, community hospital-based study showed that the diagnosis of malaria was initially missed in 59% of cases and that the average delay before treatment of P. falciparum malaria was 7.6 days (81).

Comments:

• A searchable database of travel clinic specialists that may be helpful in the treatment of malaria can be found at http://www.astmh.org/source/ClinicalDirectory/.