Therapeutic decisions are based on the severity of the illness, the agent, and whether the patient may be infected with chloroquine-resistant P. falciparum.2!0 If P. falciparum infection can be excluded, most persons can be managed in the ambulatory setting. Close follow-up, including repeated smears, is necessary. Patients with significant hemolysis or who have underlying severe chronic medical problems that can be aggravated by high fevers or hemolysis are best hospitalized. Infected infants and pregnant women are also best managed in the hospital.

Chloroquine is the drug of choice for treatment of infection due to P. vivax, P. ovale, and P. malariae. T.a.ble.,142.-4 summarizes the treatment regimens for malaria. With treatment, the parasite load should decrease significantly within the first 24 to 48 h. No asexual forms of the parasite should be detectable 3 to 4 days after treatment is completed. Gametocytes, the sexual forms, which do not cause disease in the human host, may persist for several weeks after treatment and are not an indicator of treatment failure. Chloroquine has no effect on the exoerythrocytic parasites, which may be dormant in the liver with infection due to P. vivax and P. ovale. Unless terminal treatment is administered with primaquine, clinical relapses commonly occur. Primaquine should not be used in patients with glucose-6-phosphate dehydrogenase deficiency, because primaquine may induce massive hemolysis of erythrocytes. Ta.ble.,142.-5 summarizes the commonly described adverse effects and precautions or contraindications of the antimalarial medications. Despite treatment with both chloroquine and primaquine, infection or relapse may persist.

TABLE 142-4 Treatment Regimens for Malaria

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