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Three Part Question

In [stable patients returning to developed countries with Plasmodium falciparum] is [outpatient management as effective as in patient] [in preventing adverse events]?

Clinical Scenario

A 45 year old man returns to the UK after spending 3 months working in Kenya. He complains of headache, myalgia and nausea. He is not vomiting, his observations are stable and his temperature remains below 38 degrees Celsius. Blood film confirms the presence of Plasmodium falciparum malaria parasites.

Search Strategy

Ovid MEDLINE(R) 1946 to October Week 2 2013
[ti. malaria] AND [ti. outpatient OR ti. ambulatory OR ti. admission]

Search Outcome

36 papers found on initial search. However, majority of papers were based on studies in children and/or set in developing countries where ambulatory care was a must (due to lack of availability of hospital care) rather than an innovation.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
D'Acremont et al. 2002 Switzerland	129 with malaria. 82 had P.falciparum. Exclusion criteria: Temp>40°C, poor general condition, jaundice, vomiting, bleeding, pregnant, respiratory or neurological problems, parasitaemia >2%, Hb <80g/dl, hypoglycaemia, hypotension, platelets <20, creatinine >250 μmol/ml.	Prospective cohort study.	How many readmitted?	6 (4.7%). 5 (3.9%) with P.falciparum.	No ‘white patients’. No randomisation of patients suitable for outpatient management.
			Ambulatory patients suffering adverse effects?	One patient with P. falciparum required assisted ventilation but all recovered fully.
Melzer, M. 2006 UK	41 patients with P. falciparum. Exclusion criteria: age>16, not pregnant, not of white ethnic group, ‘clinically well’, parasitaemia >2%, vomiting, abnormal renal function.	Letter to Journal Editor.	How many were managed as outpatients?	41	Small numbers. Excluded ‘white ethnic’ patients. No follow up to ensure cure. No randomisation of patients suitable for outpatient management.
			How many readmitted?	None
			How many patients given ambulatory care for malaria suffered adverse effects as a consequence?	None
Bottieau et al. 2007 Belgium	214 patients with P.falciparum. Included returning Western travellers and expatriates. Exclusion criteria included respiratory distress, multiple convulsions, circulatory collapse, pulmonary oedema, abnormal bleeding, jaundice, haemaglobinuria and severe anaemia.	5 year prospective cohort study.	How many patients were readmitted?	10 (4.7%)	No randomisation of patients suitable for outpatient management.
			How many patients given ambulatory care for malaria suffered adverse effects as a consequence?	All recovered without malaria related complications.
			How many patients were followed up?	209/214 (97.7%) had subjective clinical cure by telephone consultation within 1 week.
Melzer et al 2009 UK	52 patients with P. Falciparum. Exclusion criteria: age>16, not pregnant, UK born, alert and orientated, normotensive, parasitaemia >2%, vomiting, abnormal renal function.	3 year prospective study.	How many patients readmitted?	None.	No randomisation of patients suitable for outpatient management. UK-born patients excluded. 15 patients lost to follow up.
			How many patients given ambulatory care for malaria suffered adverse effects as a consequence?	None.

Comment(s)

There is evidence to suggest that outpatient management of malaria may be safe in selected patients who are not vomiting and do not have any of the WHO severe malaria criteria. Three out of the four papers excluded white patients and may be less generalisable to UK emergency department practice. Of all the patients who had ambulatory malaria management, all recovered fully and only one, who required assisted ventilation, had any serious complications. Larger, randomised trials comparing ambulatory and inpatient groups would help to answer the question better and studies into what criteria would allow safe ambulatory management should be performed.

Clinical Bottom Line

In selected patients with Plasmodium falciparum malaria ambulatory management may be a safe alternative to inpatient management, although the current UK guidance advocates initial admission for all patients.

References

1. D'Acremont V, Landry P, Darioli R, et al. Treatment of imported malaria in an ambulatory setting: prospective study. BMJ 2002;324:875–7.
2. Melzer, M. Outpatient treatment of falciparum malaria is possible. BMJ 2006;333:397–8.
3. Bottieau, E; Clerinx, J; Colebunders, R et al. Selective ambulatory management of imported falciparum malaria: a 5-year prospective study. Eur J Clin Microbiol Infect Dis 2007;26:181–8
4. Melzer M, Lacey S, Rait G. The case for outpatient treatment of Plasmodium falciparum malaria in a selected UK immigrant population. J Infect 2009;59:259–63.