Plasmodium falciparum drug resistance has considerably modified the attitude of physicians in terms of malaria case management. However, a bad understanding of the resistance phenomenon can lead to non-appropriate therapeutic and/or public health practices. The objective of this paper was to contribute to clarify the concept of parasitological resistance by analysing the different types of resistance observed in vivo. We showed through some examples that the precision of in vivo parasitological results depends on the type of microscopical technique used. We also showed that the classification system into resistance levels RI, RII, and RIII does not correspond to an increase in the resistance of the parasite itself but rather to an increase in the proportion of the resistant strains compared to the sensitive ones circulating in a given population. Mutant strains are circulating in low proportions as long as there is no selective drug pressure. They can be first detected in vitro and, later on, when their proportion increase, they are detected in vivo, first in non-immune subjects and later in semi-immune subjects. Therefore, the role of the host immunity is important in malaria drug resistance. To conclude, increasing use of antimalarial drugs (especially in monotherapy) cannot thwart the resistance, but rather leads to the selection of mutants strains. As the proportion of the mutant strains increases compared to the sensitive (wild) ones, it will reach the microscopic detection level and then, the clinical level. It is important that physicians involved in malaria case management understand these notions in order to avoid non-appropriate therapeutic decisions.
Copyright John Libbey Eurotext 2003.