Connor uses an algorithm based on the antimalarial sensitivity in a region to help guide malarial prophylaxis in travelers. The author is from the New York Center for Travel and Tropical Medicine in New York City.
Steps:
(1) Determine if the traveler requires prophylaxis.
(2) Determine regimen based on sensitivity in region.
(3) Look for contraindications to help select candidate agent(s).
(4) Troubleshoot the patient who requires prophylaxis but who cannot take recommended drug.
Step 1: Is the risk of malaria sufficient to warrant prophylaxis? If no, then none given.
Step 2: If risk is sufficient to warrant prophylaxis, determine regimen.
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Malaria in Region
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Drug Factor
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Regimen Choices
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chloroquine sensitive
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able to take chloroquine
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chloroquine
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|
chloroquine sensitive
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unable to take chloroquine due to intolerance or contraindication
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mefloquine, or
doxycycline, or
atovaquone/proguanil
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chloroquine resistant
|
|
mefloquine, or
doxycycline, or
atovaquone/proguanil
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|
mefloquine resistant
|
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doxycycline, or
atovaquone/proguanil
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Step 3: Determine if drug cannot be used because of contraindication.
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Drug
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Major Contraindications
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|
chloroquine
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hepatic insufficiency
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mefloquine
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seizure disorder, cardiac conduction disturbance, history of depression or mental illness
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|
doxycycline
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sun exposure (phototoxicity), pediatric patient, pregnancy, hepatic insufficiency, renal insufficiency, possibly yeast infection
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|
atovaquone/proguanil
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renal insufficiency, uncertain for use in pregnancy
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where:
• According to the Sanford Guide to Antimicrobial Therapy (page 120 in 1999 edition), doxycycline can be used in pediatric patients >= 8 years of age.
Step 4: If none of the recommended drugs can be taken, then
(a) Consider change in travel plans to eliminate malaria risk. For example, delay in travel until after delivery in a pregnant woman, reduced sun exposure if doxycycline selected.
(b) Determine if anti-mosquito measures alone is sufficient protection.
(c) Refer the patient to an expert.
