BACKGROUND: The aim of this study was to evaluate the rates of parasitaemia clearance and the prevalence of treatment failure in patients with uncomplicated Plasmodium falciparum malaria treated with artemether-lumefantrine (AL), mefloquine (MQ), and atovaquone-proguanil (AP). METHOD: The retrospective descriptive study included adult patients with uncomplicated P. falciparum malaria treated at the University Hospital Bulovka in Prague from 2006 to 2019. Parasitaemia clearance was estimated using a linear regression model. RESULTS: The study included 72 patients with a median age of 33 years (IQR 27-45) and a male to female ratio of 3.2:1. Thirty-six patients (50.0%) were treated with AL, 27 (37.5%) with MQ and 9 (12.5%) with AP. The proportion of VFR and migrants was 22.2% with no significant differences among the three groups. The median time to the parasitaemia clearance was two days (IQR 2-3) in patients treated with AL versus four days in the MQ (IQR 3-4) and AP (IQR 3-4) groups, p < 0.001. The clearance rate constant was 3.3/hour (IQR 2.5-4.0) for AL, 1.6/hour (IQR 1.3-1.9) for MQ, and 1.9/hour (IQR 1.3-2.4) for AP, p < 0.001. Malaria recrudescence occurred in 5/36 (13.9%) patients treated with AL and in no patients treated with MQ or AP. CONCLUSIONS: The findings demonstrate the superior efficacy of AL compared to other oral antimalarials in early malaria treatment. However, we observed a higher rate of late treatment failure in patients treated with AL than previously reported. This issue warrants further investigation of possible dose adjustments, extended regimens, or alternative artemisinin-based combinations.

• Keywords
• Antimalarials, Artemether-lumefantrine, Artemisinin-based combination therapy, Atovaquone-proguanil, Malaria, Mefloquine, Travel medicine, Travellers,
• MeSH
• Antimalarials * adverse effects   MeSH
• Artemether therapeutic use   MeSH
• Adult MeSH
• Ethanolamines therapeutic use   MeSH
• Drug Combinations MeSH
• Artemether, Lumefantrine Drug Combination therapeutic use   MeSH
• Middle Aged MeSH
• Humans MeSH
• Malaria * drug therapy   MeSH
• Mefloquine therapeutic use   adverse effects   MeSH
• Treatment Failure MeSH
• Plasmodium falciparum MeSH
• Retrospective Studies MeSH
• Malaria, Falciparum * drug therapy   epidemiology   MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Names of Substances
• Antimalarials * MeSH
• Artemether MeSH
• atovaquone, proguanil drug combination MeSH Browser
• Ethanolamines MeSH
• Drug Combinations MeSH
• Artemether, Lumefantrine Drug Combination MeSH
• Mefloquine MeSH

BACKGROUND: Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisinin-based combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisinin-based treatment (ABT) versus non-ABTs in the first trimester of pregnancy. METHODS: For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371. FINDINGS: We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5·7%) of 736 ABT-exposed pregnancies compared with 96 (8·9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0·71, 95% CI 0·49-1·03). Similar results were seen for the individual components of miscarriage (aHR=0·74, 0·47-1·17), stillbirth (aHR=0·71, 0·32-1·57), and major congenital anomalies (aHR=0·60, 0·13-2·87). The risk of adverse pregnancy outcomes was lower with artemether-lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4·8%] of 524 vs 84 [9·2%] of 915; aHR 0·58, 0·36-0·92). INTERPRETATION: We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether-lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether-lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether-lumefantrine is unavailable, other ACTs (except artesunate-sulfadoxine-pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted. FUNDING: Medicines for Malaria Venture, WHO, and the Worldwide Antimalarial Resistance Network funded by the Bill & Melinda Gates Foundation.

• MeSH
• Antimalarials * adverse effects   MeSH
• Artemether therapeutic use   MeSH
• Quinine adverse effects   MeSH
• Ethanolamines therapeutic use   MeSH
• Drug Combinations MeSH
• Artemether, Lumefantrine Drug Combination therapeutic use   MeSH
• Humans MeSH
• Malaria * drug therapy   MeSH
• Stillbirth epidemiology   MeSH
• Prospective Studies MeSH
• Pregnancy Trimester, First MeSH
• Abortion, Spontaneous * MeSH
• Pregnancy MeSH
• Malaria, Falciparum * drug therapy   MeSH
• Pregnancy Outcome MeSH
• Check Tag
• Humans MeSH
• Pregnancy MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Meta-Analysis MeSH
• Research Support, Non-U.S. Gov't MeSH
• Systematic Review MeSH
• Names of Substances
• Antimalarials * MeSH
• Artemether MeSH
• artemisinin MeSH Browser
• Quinine MeSH
• Ethanolamines MeSH
• Drug Combinations MeSH
• Artemether, Lumefantrine Drug Combination MeSH

Malaria represents the most important parasitic infection imported from the tropics causing death in 1-2 % of travelers with this diagnosis. Around 30 cases of malaria are diagnosed in the Czech Republic every year. Fever is the most common clinical presentation. The most severe forms of malaria are caused by Plasmodium falciparum. The diagnosis of malaria is based on examination of stained thick and thin blood smears. This method enables determination of Plasmodium species and parasite count. The treatment of ma-laria has to be initiated immediately after the laboratory confirmation. In the Czech Republic, uncomplicated falciparum malaria is treated by oral administration of artemether/lumefantrine or atovaquone/proguanil. Complicated falciparum malaria is treated by parenteral administration of quinine in combination with clindamycin. For the chemoprophylaxis of malaria in travelers to the highly endemic regions, atovaquone/proguanil, doxycycline or mefloquine are recommended.

• MeSH
• Antimalarials therapeutic use   MeSH
• Travel * MeSH
• Humans MeSH
• Malaria drug therapy   epidemiology   MeSH
• Malaria, Falciparum drug therapy   epidemiology   MeSH
• Check Tag
• Humans MeSH
• Male MeSH
• Publication type
• Journal Article MeSH
• Geographicals
• Czech Republic epidemiology   MeSH
• Names of Substances
• Antimalarials MeSH