Ambulatory care in well adults diagnosed with malaria in the emergency department.
Date First Published:
February 22, 2013
Last Updated:
April 30, 2014
Report by:
Thomas Palmer, FY2 in Emergency Medicine (Stepping Hill Hospital)
Search checked by:
Peter Hulme, Stepping Hill Hospital
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
Search Details:
[ti. malaria] AND [ti. outpatient OR ti. ambulatory OR ti. admission]
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Treatment of imported malaria in an ambulatory setting: prospective study. D'Acremont V, Landry P, Darioli R, 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. | ||||
| Outpatient treatment of falciparum malaria is possible. 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? | |||||
| How many patients given ambulatory care for malaria suffered adverse effects as a consequence? | |||||
| Selective ambulatory management of imported falciparum malaria: a 5-year prospective study. Bottieau, E; Clerinx, J; Colebunders, R 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. | ||||
| The case for outpatient treatment of Plasmodium falciparum malaria in a selected UK immigrant population. Melzer M, Lacey S, Rait G. 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. |
Author Commentary:
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.
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:
- D'Acremont V, Landry P, Darioli R, et al. . Treatment of imported malaria in an ambulatory setting: prospective study.
- Melzer, M.. Outpatient treatment of falciparum malaria is possible.
- Bottieau, E; Clerinx, J; Colebunders, R et al.. Selective ambulatory management of imported falciparum malaria: a 5-year prospective study.
- Melzer M, Lacey S, Rait G.. The case for outpatient treatment of Plasmodium falciparum malaria in a selected UK immigrant population.