No Clinical or Molecular Evidence of Plasmodium falciparum Resistance to Artesunate–Mefloquine in Northwestern Brazil

Simone Ladeia-Andrade Laboratory of Parasitic Diseases, Oswaldo Cruz Institute/Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil.
Amazonian Malaria Initiative/Amazon Network for the Surveillance of Antimalarial Drug Resistance, Ministry of Health of Brazil, Cruzeiro do Sul, Brazil.

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Gladson Naber P. de Melo Amazonian Malaria Initiative/Amazon Network for the Surveillance of Antimalarial Drug Resistance, Ministry of Health of Brazil, Cruzeiro do Sul, Brazil.

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Rita de Cássia de Souza-Lima Amazonian Malaria Initiative/Amazon Network for the Surveillance of Antimalarial Drug Resistance, Ministry of Health of Brazil, Cruzeiro do Sul, Brazil.

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Laís C. Salla Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.

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Melissa S. Bastos Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.

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Priscila T. Rodrigues Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.

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Francisco das Chagas O. Luz Center for Tropical Medicine, University of Brasília, Brasília, Brazil.

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Marcelo U. Ferreira Amazonian Malaria Initiative/Amazon Network for the Surveillance of Antimalarial Drug Resistance, Ministry of Health of Brazil, Cruzeiro do Sul, Brazil.
Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.

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We evaluated the clinical efficacy of artesunate–mefloquine (ASMQ) fixed-dose combination to treat uncomplicated malaria in Juruá Valley, the main Plasmodium falciparum transmission hotspot in Brazil. Between November 2010 and February 2013, we enrolled 162 patients aged 4–73 years, with fever or a history of fever, and a single-species P. falciparum infection confirmed by microscopy and polymerase chain reaction (PCR). All 154 patients who completed the 42-day follow-up presented an adequate clinical and parasitologic response. ASMQ was well tolerated and no adverse event caused treatment interruption. Gametocytes were detected in 46.3% patients; 35.2% had gametocytes at enrollment, whereas others developed patent gametocytemia 1–14 days after starting ASMQ. By day 3 of treatment, all subjects had cleared asexual parasitemia, but parasite DNA remained PCR detectable in 37.6% of them. Day-3 PCR positivity was associated with prolonged gametocyte carriage. We found no molecular evidence of resistance to either MQ (pfmdr1 gene amplification) or AS (mutations in selected kelch13 gene domains known to be associated with AS resistance) in the local P. falciparum population. These results strongly support the use of ASMQ as a first-line regimen to treat uncomplicated P. falciparum malaria in northwestern Brazil, but underscore the need for gametocytocidal drugs to reduce the transmission potential of ASMQ-treated patients (ClinicalTrials.gov number NCT01144702).

Author Notes

* Address correspondence to Marcelo U. Ferreira, Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, Avenida Professor Lineu Prestes 1374, Cidade Universitária, São Paulo, Brazil 05508-900. E-mail: muferrei@usp.br

Financial support: This clinical study was supported by the Amazonian Malaria Initiative (AMI)/Amazon Network for the Surveillance of Antimalarial Drug Resistance (RAVREDA) through the Pan American Health Organization (PAHO; BR/LOA/0900212.001), Ministry of Health of Brazil, and Oswaldo Cruz Foundation (cooperation agreements 25380.4120/09-26 and 82/2012). AMI is a partnership of the U.S. Agency for International Development with PAHO, Centers for Disease Control and Prevention (CDC), the Management Sciences for Health's Rational Pharmaceutical Management Plus (MSH/RPM Plus) program, the U.S. Pharmacopoeia, and Links Media, Inc. RAVREDA was organized in 2001 by several countries with PAHO's support to respond to the challenge of antimalarial drug resistance in the Amazon. Laboratory work was partially supported by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil (grant 404067/2012-3). Laís C. Salla, Priscila T. Rodrigues, and Marcelo U. Ferreira are supported by CNPq scholarships.

Authors' addresses: Simone Ladeia-Andrade, Laboratory of Parasitic Diseases, Oswaldo Cruz Institute/Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil and Amazonian Malaria Initiative/Amazon Network for the Surveillance of Antimalarial Drug Resistance, Regional Hospital of Juruá Valley, Cruzeiro do Sul, Brazil, E-mail: shawam@uol.com.br. Gladson Naber P. de Melo and Rita de Cássia de Souza-Lima, Amazonian Malaria Initiative/Amazon Network for the Surveillance of Antimalarial Drug Resistance, Regional Hospital of Juruá Valley, Cruzeiro do Sul, Brazil, E-mails: gladson_melo@hotmail.com and draritalima@yahoo.com.br. Laís C. Salla, Melissa S. Bastos, Priscila T. Rodrigues, and Marcelo U. Ferreira, Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil, E-mails: lais.salla@usp.br, melissabastos@yahoo.com.br, priscilathihara@usp.br, and muferrei@usp.br. Francisco das Chagas O. Luz, Center for Tropical Medicine, Campus Universitário Darcy Ribeiro, University of Brasília, Brasília, Brazil, E-mail: franciluz@yahoo.com.br.

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