Patients planning to travel to other countries often ask physicians for information about appropriate vaccines and prevention of diarrhea and malaria. Guidelines are also available from the Infectious Diseases Society of America (IDSA).

Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment could also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

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The drug of choice for patients who require parenteral treatment for malaria is IV artesunate, which is available now from the CDC Malaria Branch (M-F, 8 AM-4:30 PM eastern time, 770-488-7788 or, after hours, 770-488-7100). Artesunate appears to be more effective than quinine1 and safer than quinidine, the other parenteral alternatives in the US. The CDC has supplies of artesunate in Atlanta and in 8 quarantine stations in major airports around the US. It will release the drug for appropriate patients (severe disease or unable to take oral drugs) if it can be supplied as quickly as quinidine, or if quinidine has failed, been poorly tolerated, or is contraindicated.

The herbal artemisinin derivatives artemether and artesunate are used worldwide for treatment of malaria caused by Plasmodium falciparum, but have not been marketed in the US.2,3 About 1500 cases of malaria are diagnosed each year in the US in returning travelers, and about 5% of these have severe disease.4

Artesunate is generally given over 3 days in 2.4 mg/kg doses at 0, 12, 24 and 48 hours. It should be accompanied as soon as possible by an oral drug such as atovaquone/proguanil (Malarone), doxycycline (Vibramycin, and others; not for children <8 years old), clindamycin (Cleocin, and others) or mefloquine (Lariam, and others).

1. A Dondorp et al. South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet 2005; 366:717.
2. Drugs for parasitic infections. New Rochelle, NY: The Medical Letter; 2007:34.
3. NJ White. Qinghaosu (artemisinin): the price of success. Science 2008; 320:330.
4. PJ Rosenthal. Artesunate for the treatment of severe falciparum malaria. N Engl J Med 2008; 358:1829.

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Patients planning to travel to other countries often ask physicians for information about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control and Prevention at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

Many patients planning to travel seek advice about prevention of malaria. No drug is 100% effective for this indication; travelers should be told to take other protective measures as well. Malaria in pregnancy is particularly serious for both mother and fetus; prophylaxis is indicated if travel cannot be avoided. Countries with a risk of malaria are listed in the table on page 102. Some countries with endemic malaria transmission may not have malaria in the most frequently visited major cities and rural tourist resorts.

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Parasitic infections are found throughout the world. With increasing travel, immigration, use of immunosuppressive drugs and the spread of AIDS, physicians anywhere may see infections caused by previously unfamiliar parasites. The table below lists first-choice and alternative drugs for most parasitic infections. The brand names and manufacturers of the drugs are listed in this article.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control (CDC) at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel. Recommendations for the treatment of parasitic diseases are available in the public reading room of The Medical Letter's web site.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the CDC at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

Superseded--purchase updated Parasitic Infections article
Parasitic infections are found throughout the world. With increasing travel, immigration, use of immunosuppressive drugs and the spread of AIDS, physicians anywhere may see infections caused by previously unfamiliar parasites.

Note: Drugs for Parasitic Infections, revised and updated, is now available to both subscribers and nonsubscribers on our web site. This article, a bi-annual feature of The Medical Letter for many years, will not be published as a printed issue in 2002, but is included in the 16th edition of The Medical Letter Handbook of Antimicrobial Therapy. The handbook is now available and can be ordered by calling customer service at 1-800-211-2769.

A fixed-dose combination of atovaquone and proguanil hydrochloride has been approved by the FDA for oral prophylaxis and treatment of malaria due to Plasmodium falciparum, including choloroquine-resistant strains.

Older patients are especially susceptible to drug-induced cognitive impairment. They are more likely to be taking multiple drugs, to have higher blood levels of those drugs because of renal or hepatic dysfunction, and to have pre-existing cognitive problems that make it difficult to detect the role of drugs causing new symptoms or making old ones worse.

Patients planning to travel often ask for advice on prophylaxis against malaria. None of the antimalarials used in the past for prophylaxis has been entirely satisfactory.

Patients planning to travel to other countries often ask pysicians for advice about immunizations and prevention of diarrhea and malaria. Legal requirements for entry and epidemiological conditions in different countries vary from time to time, often unpredictably, but some reasonable recommendations can be made.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the CDC at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. Legal requirements for entry and epidemiological conditions in different countries vary from time to time, often unpredictably, but some reasonable recommendations can be made. More detailed information is available in Health Information for International Travel, published annually by the Centers for Disease Control (CDC), which can be obtained from the Superintendent of Documents, US Government Printing Office, Washington, DC 20402. Up-to-date automated information is available by telephone from the CDC (404-332-4559).

Four different desk-top systems are now widely used in physicians'; offices to measure blood chemistries. The Ektachem DT (Kodak) and Reflotron (Boehringer Mannheim), reviewed previously in The Medical Letter (volume 30, page 119, 1988; volume 31, page 90, 1989), resemble the Seralyzer (Miles Diagnostics) in cost; the Vision (Abbott), which is fully automated, is much more expensive.

Mefloquine hydrochloride (Lariam - Roche), a new antimalarial drug chemically related to quinine, has been approved by the US Food and Drug Administration (FDA) for prevention and treatment of Plasmodium falciparum and P. vivax malaria.