Treatment of P. falciparum infection is generally best managed in a hospital setting, particularly if the level of parasitemia exceeds 3 percent. Unless one is certain that the patient could not have chloroquine-resistant falciparum infection (based on geographic exposure, Ta.ble.,142.-1), it is best to assume the infecting strain is resistant to chloroquine and to initiate treatment with a combination of quinine and doxycycline with or without pyrimethamine-sulfadoxine. Quinine may at times be in short supply, since only firms that specialize in generic drugs currently manufacture the product. Mefloquine is also an effective therapy for chloroquine-resistant P. falciparum (and the asexual erythrocyte stages of the other Plasmodium species). Halofantrine, a recently introduced antimalarial compound, may have a limited role for self-treatment of presumptive malaria acquired in Southeast Asia or if multiple drug-resistant malaria is suspected.
Persons presenting with complications caused by P. falciparum or with high parasitemia but unable to tolerate oral medications due to vomiting should receive intravenous medications. Supportive care is critical for these patients and includes close hemodynamic monitoring, use of judicious fluid replacement, correction of significant metabolic abnormalities, and additional support as needed (dialysis, mechanical ventilation, and so on). Exchange transfusions have been lifesaving in some patients with parasitemia in excess of 10 percent. Glucocorticoids have not been shown to be of benefit in the treatment of cerebral malaria and should not be used.11 Quinidine is the intravenous drug of choice due not only to its widespread availability but also to its enhanced activity against P. falciparum. Parenteral quinine is available only from the Centers for Disease Control and Prevention.
Quinine and quinidine are potent inducers of insulin release and may cause severe hypoglycemia. Sudden changes in orientation, sweating, tremor, tachycardia, or anxiety should prompt measurement of plasma glucose concentration. Cinchona alkaloids are myocardial depressants, so cardiac monitoring is needed during administration. Terminal treatment with primaquine is not needed in patients with P. falciparum malaria, due to the absence of dormant asexual forms in the liver.
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