Drugs for parasitic infections

Medical Letter on Drugs and Therapeutics

Volumn 40, Issue 1017, 1998, Pages 1-12

  Abramowicz, Mark ^d   Rizack, Martin A ^a   Goodstein, Donna ^d   Faucard, Amy ^d   Hansten, Philip D ^b   Steigbigel, Neal H ^c  

^a ROCKEFELLER UNIVERSITY   (United States)

^b UNIVERSITY OF WASHINGTON   (United States)

^c ALBERT EINSTEIN COLLEGE OF MEDICINE   (United States)

^d NONE

Author keywords

[No Author keywords available]

Indexed keywords

ALBENDAZOLE; ANTHELMINTIC AGENT; ANTIPARASITIC AGENT; ANTIPROTOZOAL AGENT; ARTEMETHER; ATOVAQUONE; BENZNIDAZOLE; BITHIONOL; CHLOROQUINE; CROTAMITON; DIETHYLCARBAMAZINE; DIIODOHYDROXYQUIN; DILOXANIDE FUROATE; EFLORNITHINE; FURAZOLIDONE; HALOFANTRINE; IVERMECTIN; MEBENDAZOLE; MEFLOQUINE; MELARSOPROL; METRONIDAZOLE; NIFURTIMOX; ORNIDAZOLE; OXAMNIQUINE; PAROMOMYCIN; PENTAMIDINE ISETHIONATE; PERMETHRIN; PRAZIQUANTEL; PRIODERMA; PROGUANIL; PYRANTEL EMBONATE; PYRETHRIN; PYRIMETHAMINE; SPIRAMYCIN; STIBOGLUCONATE SODIUM; TIABENDAZOLE; TINIDAZOLE; TRICLABENDAZOLE; TRIMETREXATE GLUCURONATE; UNCLASSIFIED DRUG;

ABDOMINAL PAIN; ALOPECIA; AMEBIASIS; ATAXIA; COMA; HELMINTHIASIS; HUMAN; INTRAVENOUS DRUG ADMINISTRATION; LIVER TOXICITY; NEPHROTOXICITY; NEUROTOXICITY; ORAL DRUG ADMINISTRATION; PARASITOSIS; PROTOZOAL INFECTION; RASH; REVIEW; URTICARIA;

AMEBICIDES; ANTIMALARIALS; ANTIPARASITIC AGENTS; ANTITRICHOMONAL AGENTS; COCCIDIOSTATS; HUMANS; PARASITIC DISEASES; TRYPANOCIDAL AGENTS;

EID: 0002778844     PISSN: 0025732X     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (123)

1. Trophozoites and cysts of Acanthamoeba from infected corneas, contact lenses and their cases are susceptible in vitro to chlorhexidine, polyhexamethylene biguanide, propamidine, pentamidine, diminazine and neomycin and, especially, to combinations of these drugs (J Hay et al, Eye, 8:555, 1994). For treatment of keratitis, oral itraconazole plus topical miconazole (Y Ishabashi et al, Am J Ophthalmol, 109:121, 1990) or topical 0.02% polyhexamethylene biguanide (PHMB) plus 0.1% propamidine isethionate (Brolene) have been successful (IGM Duguid et al, Ophthalmology, 104:1587, 1997). PHMB is available as Baquacil (Zeneca), a swimming pool disinfectant (E Yee and TK Winarko, Am J Hosp Pharm, 50:2523, 1993).
2. Trophozoites and cysts of Acanthamoeba from infected corneas, contact lenses and their cases are susceptible in vitro to chlorhexidine, polyhexamethylene biguanide, propamidine, pentamidine, diminazine and neomycin and, especially, to combinations of these drugs (J Hay et al, Eye, 8:555, 1994). For treatment of keratitis, oral itraconazole plus topical miconazole (Y Ishabashi et al, Am J Ophthalmol, 109:121, 1990) or topical 0.02% polyhexamethylene biguanide (PHMB) plus 0.1% propamidine isethionate (Brolene) have been successful (IGM Duguid et al, Ophthalmology, 104:1587, 1997). PHMB is available as Baquacil (Zeneca), a swimming pool disinfectant (E Yee and TK Winarko, Am J Hosp Pharm, 50:2523, 1993).
3. Trophozoites and cysts of Acanthamoeba from infected corneas, contact lenses and their cases are susceptible in vitro to chlorhexidine, polyhexamethylene biguanide, propamidine, pentamidine, diminazine and neomycin and, especially, to combinations of these drugs (J Hay et al, Eye, 8:555, 1994). For treatment of keratitis, oral itraconazole plus topical miconazole (Y Ishabashi et al, Am J Ophthalmol, 109:121, 1990) or topical 0.02% polyhexamethylene biguanide (PHMB) plus 0.1% propamidine isethionate (Brolene) have been successful (IGM Duguid et al, Ophthalmology, 104:1587, 1997). PHMB is available as Baquacil (Zeneca), a swimming pool disinfectant (E Yee and TK Winarko, Am J Hosp Pharm, 50:2523, 1993).
4. Trophozoites and cysts of Acanthamoeba from infected corneas, contact lenses and their cases are susceptible in vitro to chlorhexidine, polyhexamethylene biguanide, propamidine, pentamidine, diminazine and neomycin and, especially, to combinations of these drugs (J Hay et al, Eye, 8:555, 1994). For treatment of keratitis, oral itraconazole plus topical miconazole (Y Ishabashi et al, Am J Ophthalmol, 109:121, 1990) or topical 0.02% polyhexamethylene biguanide (PHMB) plus 0.1% propamidine isethionate (Brolene) have been successful (IGM Duguid et al, Ophthalmology, 104:1587, 1997). PHMB is available as Baquacil (Zeneca), a swimming pool disinfectant (E Yee and TK Winarko, Am J Hosp Pharm, 50:2523, 1993).
5. Treatment should be followed by a course of iodoquinol or paromomycin in the dosage used to treat asymptomatic amebiasis.
6. A nitro-imidazole similar to metronidazole, but not marketed in the USA, tinidazole appears to be at least as effective as metronidazole and better tolerated. Ornidazole, a similar drug, is also used outside the USA. Higher dosage is for hepatic abscess.
7. Naegleria infections have been treated successfully with amphotericin B, rifampin and chloramphenicol (A Wang et al, Clin Neurol Neurosurg, 95:249, 1993), amphotericin B, oral rifampin and oral ketoconazole (N Poungvarin et al, J Med Assoc Thailand, 74:112, 1991), or amphotericin B alone (RL Brown, Arch Intern Med, 152:1330, 1992).
8. Naegleria infections have been treated successfully with amphotericin B, rifampin and chloramphenicol (A Wang et al, Clin Neurol Neurosurg, 95:249, 1993), amphotericin B, oral rifampin and oral ketoconazole (N Poungvarin et al, J Med Assoc Thailand, 74:112, 1991), or amphotericin B alone (RL Brown, Arch Intern Med, 152:1330, 1992).
9. Naegleria infections have been treated successfully with amphotericin B, rifampin and chloramphenicol (A Wang et al, Clin Neurol Neurosurg, 95:249, 1993), amphotericin B, oral rifampin and oral ketoconazole (N Poungvarin et al, J Med Assoc Thailand, 74:112, 1991), or amphotericin B alone (RL Brown, Arch Intern Med, 152:1330, 1992).
10. An approved drug, but considered investigational for this condition by the U.S. Food and Drug Administration
11. Strains of Acanthamoeba isolated from fatal granulomatous amebic encephalitis are usually susceptible in vitro to pentamidine, ketoconazole (Nizoral), flucytosine (Ancobon) and (less so) to amphotericin B. One patient with disseminated infection was treated successfully with intravenous pentamidine isethionate, topical chlorhexidine and 2% ketoconazole cream, followed by oral itraconazole (CA Slater et al, N Engl J Med, 331:85, 1994).
12. Antiparasitic drugs can provoke neurologic symptoms, and most patients recover spontaneously without them. Analgesics, corticosteroids, and careful removal of CSF at frequent intervals can relieve symptoms (J Koo et al, Rev Infect Dis, 10:1155, 1988). Albendazole, levamisole (Ergamisol), or ivermectin have been used successfully in animals.
13. This dose is likely to be toxic and may have to be decreased.
14. Atovaquone suspension, 750 mg b.i.d., plus azithromycin, 500 to 1000 mg daily, may be effective when quinine and clindamycin fail (M Wittner et al, Am J Trop Med Hyg, 55:219, 1996). Exchange transfusion has been used in severely ill patients with high (>10%) parasitemia (V lacopino and T Earnhart, Arch Intern Med, 150:1527, 1990). One report indicates that azithromycin, 500-1000 mg daily, plus quinine may also be effective (LM Weiss et al, J Infect Dis, 168:1289, 1993). Concurrent use of pentamidine and trimethoprimsulfamethoxazole has been reported to cure an infection with B. divergens (D Raoult et al, Ann Intern Med, 107:944, 1987).
15. Atovaquone suspension, 750 mg b.i.d., plus azithromycin, 500 to 1000 mg daily, may be effective when quinine and clindamycin fail (M Wittner et al, Am J Trop Med Hyg, 55:219, 1996). Exchange transfusion has been used in severely ill patients with high (>10%) parasitemia (V lacopino and T Earnhart, Arch Intern Med, 150:1527, 1990). One report indicates that azithromycin, 500-1000 mg daily, plus quinine may also be effective (LM Weiss et al, J Infect Dis, 168:1289, 1993). Concurrent use of pentamidine and trimethoprimsulfamethoxazole has been reported to cure an infection with B. divergens (D Raoult et al, Ann Intern Med, 107:944, 1987).
16. Atovaquone suspension, 750 mg b.i.d., plus azithromycin, 500 to 1000 mg daily, may be effective when quinine and clindamycin fail (M Wittner et al, Am J Trop Med Hyg, 55:219, 1996). Exchange transfusion has been used in severely ill patients with high (>10%) parasitemia (V lacopino and T Earnhart, Arch Intern Med, 150:1527, 1990). One report indicates that azithromycin, 500-1000 mg daily, plus quinine may also be effective (LM Weiss et al, J Infect Dis, 168:1289, 1993). Concurrent use of pentamidine and trimethoprimsulfamethoxazole has been reported to cure an infection with B. divergens (D Raoult et al, Ann Intern Med, 107:944, 1987).
17. Atovaquone suspension, 750 mg b.i.d., plus azithromycin, 500 to 1000 mg daily, may be effective when quinine and clindamycin fail (M Wittner et al, Am J Trop Med Hyg, 55:219, 1996). Exchange transfusion has been used in severely ill patients with high (>10%) parasitemia (V lacopino and T Earnhart, Arch Intern Med, 150:1527, 1990). One report indicates that azithromycin, 500-1000 mg daily, plus quinine may also be effective (LM Weiss et al, J Infect Dis, 168:1289, 1993). Concurrent use of pentamidine and trimethoprimsulfamethoxazole has been reported to cure an infection with B. divergens (D Raoult et al, Ann Intern Med, 107:944, 1987).
18. Use of tetracyclines is contraindicated in pregnancy and in children less than 8 years old
19. Drugs that could be tried include albendazole, mebendazole, thiabendazole, levamisole (Ergamisol) and ivermectin. Steroid therapy may be helpful, especially in eye and CNS infections. Ocular baylisascariasis has been treated successfully using laser photocoagulation therapy to destroy the intraretinal larvae.
20. Clinical significance of these organisms is controversial, but metronidazole 750 mg tid × 10d or iodoquinol 650 mg tid × 20d anecdotally has been reported to be effective (PFL Boreham and D Stenzel, Adv Parasitol, 32:2, 1993; JS Keystone; EK Markell, Clin Infect Dis 21:102 and 104, 1995).
21. Clinical significance of these organisms is controversial, but metronidazole 750 mg tid × 10d or iodoquinol 650 mg tid × 20d anecdotally has been reported to be effective (PFL Boreham and D Stenzel, Adv Parasitol, 32:2, 1993; JS Keystone; EK Markell, Clin Infect Dis 21:102 and 104, 1995).
22. Infection is self-limited in immunocompetent patients. Duration of treatment is uncertain.
23. HD Davies et al, Arch Dermatol, 129:588, 1993.
24. HIV-infected patients may need higher dosage and long-term maintenance (JW Pape et al, Ann Intern Med, 121:654, 1994).
25. Not curative, but decreases inflammation and facilitates removing the worm. Mebendazole 400-800 mg/d for 6d has been reported to kill the worm directly.
26. A single dose of ivermectin, 20-200 μg/kg, is effective for treatment of microfilaremia but does not kill the adult worm. Use of single doses of ivermectin 200-400 μg/kg and albendazole 400 mg has been more effective than ivermectin alone (DG Addiss et al, Lancet, 350:480, 1997).
27. Antihistamines or corticosteroids may be required to decrease allergic reactions due to disintegration of microfilariae in treatment of filarial infections, especially those caused by Loa loa.
28. For patients with no microfilariae in the blood, full doses can be given from day one.
29. In heavy infections with Loa loa, rapid killing of microfilariae can provoke an encephalopathy. Ivermectin or albendazole has been used to reduce microfilaremia (Y Martin-Prevel et al, Am J Trop Med Hyg, 48:186, 1993; AD Klion et al, J Infect Dis, 168:202, 1993; J Gardon et al, Trans R Soc Trop Med Hyg, 91:593, 1997). Apheresis has been reported to be effective in lowering microfilarial counts in patients heavily infected with Loa loa (EA Ottesen, Infect Dis Clin North Am, 7:619, 1993). Diethylcarbamazine, 300 mg once weekly, has been recommended for prevention of loiasis (TB Nutman et al, N Engl J Med, 319:752, 1988).
30. In heavy infections with Loa loa, rapid killing of microfilariae can provoke an encephalopathy. Ivermectin or albendazole has been used to reduce microfilaremia (Y Martin-Prevel et al, Am J Trop Med Hyg, 48:186, 1993; AD Klion et al, J Infect Dis, 168:202, 1993; J Gardon et al, Trans R Soc Trop Med Hyg, 91:593, 1997). Apheresis has been reported to be effective in lowering microfilarial counts in patients heavily infected with Loa loa (EA Ottesen, Infect Dis Clin North Am, 7:619, 1993). Diethylcarbamazine, 300 mg once weekly, has been recommended for prevention of loiasis (TB Nutman et al, N Engl J Med, 319:752, 1988).
31. In heavy infections with Loa loa, rapid killing of microfilariae can provoke an encephalopathy. Ivermectin or albendazole has been used to reduce microfilaremia (Y Martin-Prevel et al, Am J Trop Med Hyg, 48:186, 1993; AD Klion et al, J Infect Dis, 168:202, 1993; J Gardon et al, Trans R Soc Trop Med Hyg, 91:593, 1997). Apheresis has been reported to be effective in lowering microfilarial counts in patients heavily infected with Loa loa (EA Ottesen, Infect Dis Clin North Am, 7:619, 1993). Diethylcarbamazine, 300 mg once weekly, has been recommended for prevention of loiasis (TB Nutman et al, N Engl J Med, 319:752, 1988).
32. In heavy infections with Loa loa, rapid killing of microfilariae can provoke an encephalopathy. Ivermectin or albendazole has been used to reduce microfilaremia (Y Martin-Prevel et al, Am J Trop Med Hyg, 48:186, 1993; AD Klion et al, J Infect Dis, 168:202, 1993; J Gardon et al, Trans R Soc Trop Med Hyg, 91:593, 1997). Apheresis has been reported to be effective in lowering microfilarial counts in patients heavily infected with Loa loa (EA Ottesen, Infect Dis Clin North Am, 7:619, 1993). Diethylcarbamazine, 300 mg once weekly, has been recommended for prevention of loiasis (TB Nutman et al, N Engl J Med, 319:752, 1988).
33. In heavy infections with Loa loa, rapid killing of microfilariae can provoke an encephalopathy. Ivermectin or albendazole has been used to reduce microfilaremia (Y Martin-Prevel et al, Am J Trop Med Hyg, 48:186, 1993; AD Klion et al, J Infect Dis, 168:202, 1993; J Gardon et al, Trans R Soc Trop Med Hyg, 91:593, 1997). Apheresis has been reported to be effective in lowering microfilarial counts in patients heavily infected with Loa loa (EA Ottesen, Infect Dis Clin North Am, 7:619, 1993). Diethylcarbamazine, 300 mg once weekly, has been recommended for prevention of loiasis (TB Nutman et al, N Engl J Med, 319:752, 1988).
34. Diethylcarbamazine has no effect. Ivermectin, 6 mg once, has been effective (DD Chadee et al, Ann Trop Med Parasitol, 90:645, 1996).
35. Annual treatment with ivermectin 150 μg/kg can prevent blindness due to ocular onchocerciasis (D Mabey et al, Ophthalmology, 103:1001, 1996).
36. Unlike infections with other flukes, Fasciola hepatica infections may not respond to praziquantel. Triclabendazole (Fasinex - Novartis), a veterinary fasciolide, has been safe and effective (W Apt et al, Am J Trop Med Hyg, 52:532, 1995).
37. JD MacLean et al, Lancet, 347:154, 1996.
38. Unpublished data indicate triclabendazole (Fasinex), a veterinary fasciolide, may be effective in a dosage of 5 mg/kg once daily for 3 days or 10 mg/kg twice in one day.
39. Albendazole 400 mg daily × 5d may be effective (A Hall and Q Nahar, Trans R Soc Trop Med Hyg, 87:84, 1993). Bacitracin zinc or bacitracin 120,000 U bid for 10 days may also be effective (BJ Andrews et al, Am J Trop Med Hyg, 52:318, 1995).
40. Albendazole 400 mg daily × 5d may be effective (A Hall and Q Nahar, Trans R Soc Trop Med Hyg, 87:84, 1993). Bacitracin zinc or bacitracin 120,000 U bid for 10 days may also be effective (BJ Andrews et al, Am J Trop Med Hyg, 52:318, 1995).
41. Not absorbed; may be useful for treatment of giardiasis in pregnancy
42. Ivermectin has been reported to be effective in animals (MT Anantaphruti et al, Trop Med Parasitol, 43:65, 1992).
43. In sulfonamide-sensitive patients, pyrimethamine 50-75 mg daily has been effective (JP Ackers, Semin Gastrointest Dis, 8:33, 1997).
44. May be repeated or continued. A longer duration may be needed for some forms of visceral leishmaniasis.
45. Some studies indicate that L. donovani resistant to sodium stibogluconate or meglumine antimonate may respond to lipid-encapsulated amphotericin B (JD Berman, Clin Infect Dis, 24:684, 1997; S Sundar et al, Ann Intern Med, 127:133, 1997; L diMartino et al, J Pediatr, 131:271, 1997). The combination of aminosidine (chemically identical to paromomycin) and sodium stibogluconate has been used to cure kala-azar (CP Thakur et al, Trans R Soc Trop Med Hyg, 89:219, 1995) and diffuse cutaneous leishmaniasis caused by L. aethiopica (S Teklemariam et al, Trans R Soc Trop Med Hyg, 88:334, 1994).
46. Some studies indicate that L. donovani resistant to sodium stibogluconate or meglumine antimonate may respond to lipid-encapsulated amphotericin B (JD Berman, Clin Infect Dis, 24:684, 1997; S Sundar et al, Ann Intern Med, 127:133, 1997; L diMartino et al, J Pediatr, 131:271, 1997). The combination of aminosidine (chemically identical to paromomycin) and sodium stibogluconate has been used to cure kala-azar (CP Thakur et al, Trans R Soc Trop Med Hyg, 89:219, 1995) and diffuse cutaneous leishmaniasis caused by L. aethiopica (S Teklemariam et al, Trans R Soc Trop Med Hyg, 88:334, 1994).
47. Some studies indicate that L. donovani resistant to sodium stibogluconate or meglumine antimonate may respond to lipid-encapsulated amphotericin B (JD Berman, Clin Infect Dis, 24:684, 1997; S Sundar et al, Ann Intern Med, 127:133, 1997; L diMartino et al, J Pediatr, 131:271, 1997). The combination of aminosidine (chemically identical to paromomycin) and sodium stibogluconate has been used to cure kala-azar (CP Thakur et al, Trans R Soc Trop Med Hyg, 89:219, 1995) and diffuse cutaneous leishmaniasis caused by L. aethiopica (S Teklemariam et al, Trans R Soc Trop Med Hyg, 88:334, 1994).
48. Some studies indicate that L. donovani resistant to sodium stibogluconate or meglumine antimonate may respond to lipid-encapsulated amphotericin B (JD Berman, Clin Infect Dis, 24:684, 1997; S Sundar et al, Ann Intern Med, 127:133, 1997; L diMartino et al, J Pediatr, 131:271, 1997). The combination of aminosidine (chemically identical to paromomycin) and sodium stibogluconate has been used to cure kala-azar (CP Thakur et al, Trans R Soc Trop Med Hyg, 89:219, 1995) and diffuse cutaneous leishmaniasis caused by L. aethiopica (S Teklemariam et al, Trans R Soc Trop Med Hyg, 88:334, 1994).
49. Some studies indicate that L. donovani resistant to sodium stibogluconate or meglumine antimonate may respond to lipid-encapsulated amphotericin B (JD Berman, Clin Infect Dis, 24:684, 1997; S Sundar et al, Ann Intern Med, 127:133, 1997; L diMartino et al, J Pediatr, 131:271, 1997). The combination of aminosidine (chemically identical to paromomycin) and sodium stibogluconate has been used to cure kala-azar (CP Thakur et al, Trans R Soc Trop Med Hyg, 89:219, 1995) and diffuse cutaneous leishmaniasis caused by L. aethiopica (S Teklemariam et al, Trans R Soc Trop Med Hyg, 88:334, 1994).
50. 4 mg/kg qod × 15 doses for L. donovani; 2 mg/kg qod × 7 or 3 mg/kg qod × 4 doses for cutaneous disease.
51. A formulation of 15% paromomycin sulfate and 12% methylbenzethonium chloride in soft white paraffin topically has been reported to be effective in some patients against cutaneous leishmaniasis due to L. major (O Ozgoztasi and I Baydar, Int J Dermatol, 36:61, 1997).
52. For infestation of eyelashes with crab lice, use petrolatum.
53. A second application is recommended one week later to kill hatching progeny.
54. Medical Letter, 39:6, 1997.
55. Chloroquine-resistant P. falciparum occur in all malarious areas except Central America west of the Panama Canal Zone, Mexico, Haiti, the Dominican Republic, and most of the Middle East (chloroquine resistance has been reported in Yemen, Oman and Iran).
56. In Southeast Asia, relative resistance to quinine has increased and the treatment should be continued for seven days.
57. Fansidar tablets contain 25 mg of pyrimethamine and 500 mg of sulfadoxine. Resistance to pyrimethamine-sulfadoxine has been reported from Southeast Asia, the Amazon basin, sub-Saharan Africa, Bangladesh and Oceania.
58. For treatment of multiple-drug-resistant P. falciparum in Southeast Asia, especially Thailand, where resistance to mefloquine and halofantrine is frequent, a 7-day course of quinine and tetracycline is recommended (G Watt et al, Am J Trop Med Hyg, 47:108, 1992). Artesunate plus mefloquine (C Luxemburger et al, Trans R Soc Trop Med Hyg, 88:213, 1994), artemether plus mefloquine (J Karbwang et al, Trans R Soc Trop Med Hyg, 89:296, 1995) or mefloquine plus doxycycline are also used to treat multiple-drug-resistant P. falciparum.
59. For treatment of multiple-drug-resistant P. falciparum in Southeast Asia, especially Thailand, where resistance to mefloquine and halofantrine is frequent, a 7-day course of quinine and tetracycline is recommended (G Watt et al, Am J Trop Med Hyg, 47:108, 1992). Artesunate plus mefloquine (C Luxemburger et al, Trans R Soc Trop Med Hyg, 88:213, 1994), artemether plus mefloquine (J Karbwang et al, Trans R Soc Trop Med Hyg, 89:296, 1995) or mefloquine plus doxycycline are also used to treat multiple-drug-resistant P. falciparum.
60. For treatment of multiple-drug-resistant P. falciparum in Southeast Asia, especially Thailand, where resistance to mefloquine and halofantrine is frequent, a 7-day course of quinine and tetracycline is recommended (G Watt et al, Am J Trop Med Hyg, 47:108, 1992). Artesunate plus mefloquine (C Luxemburger et al, Trans R Soc Trop Med Hyg, 88:213, 1994), artemether plus mefloquine (J Karbwang et al, Trans R Soc Trop Med Hyg, 89:296, 1995) or mefloquine plus doxycycline are also used to treat multiple-drug-resistant P. falciparum.
61. At this dosage, adverse effects including nausea, vomiting, diarrhea, dizziness, disturbed sense of balance, toxic psychosis and seizures can occur. Mefloquine is teratogenic in animals and has not been approved for use in pregnancy, but mefloquine prophylaxis appears to be safe when used during the second half of pregnancy and possibly during early pregnancy as well (BL Smoak et al, J Infect Dis, 176:831, 1997). It should not be given together with quinine or quinidine, and caution is required in using quinine or quinidine to treat patients with malaria who have taken mefloquine for prophylaxis. The pediatric dosage has not been approved by the FDA. Resistance to mefloquine has been reported in some areas, such as the Thailand-Myanmar border, where 25 mg/kg should be used.
62. In the USA, a 250-mg tablet of mefloquine contains 228 mg mefloquine base. Outside the USA, each 275-mg tablet contains 250 mg base.
63. 750 mg followed 12 hours later by 500 mg.
64. 15 mg/kg followed 8-12 hours later by 10 mg/kg.
65. May be effective in multiple-drug-resistant P. falciparum malaria, but treatment failures and resistance have been reported, and the drug has caused lengthening of the PR and QTc intervals and fatal cardiac arrhythmias. It should not be used for patients with cardiac conduction defects. Cardiac monitoring is recommended. Variability in absorption is a problem; halofantrine should not be taken one hour before to two hours after meals because food increases its absorption.
66. A single 250-mg dose can be used for repeat treatment in mild to moderate infections (JE Touze et al, Lancet, 349:255, 1997).
67. PD Radloff et al, Lancet, 347:1511, 1996; S Looareesuwan et al, Am J Trop Med Hyg, 54:62, 1996; FEC de Alencar et al, J Infect Dis, 175:1544, 1997. Atovaquone plus proguanil is available outside the USA in a combination tablet (250 mg atovaquone, 100 mg proguanil) as Malarone.
68. PD Radloff et al, Lancet, 347:1511, 1996; S Looareesuwan et al, Am J Trop Med Hyg, 54:62, 1996; FEC de Alencar et al, J Infect Dis, 175:1544, 1997. Atovaquone plus proguanil is available outside the USA in a combination tablet (250 mg atovaquone, 100 mg proguanil) as Malarone.
69. PD Radloff et al, Lancet, 347:1511, 1996; S Looareesuwan et al, Am J Trop Med Hyg, 54:62, 1996; FEC de Alencar et al, J Infect Dis, 175:1544, 1997. Atovaquone plus proguanil is available outside the USA in a combination tablet (250 mg atovaquone, 100 mg proguanil) as Malarone.
70. P. vivax with decreased susceptibility to chloroquine has been reported in Papua-New Guinea, Indonesia, Myanmar, India, Irian Jaya and the Solomon Islands.
71. If chloroquine phosphate is not available, hydroxychloroquine sulfate is as effective; 400 mg of hydroxychloroquine sulfate is equivalent to 500 mg of chloroquine phosphate.
72. Exchange transfusion has been helpful for some patients with high-density (>10%) parasitemia, altered mental status, pulmonary edema or renal complications (KD Miller et al, N Engl J Med, 321:65, 1989).
73. Continuous EKG, blood pressure and glucose monitoring are recommended, especially in pregnant women and young children.
74. Quinidine may have greater antimalarial activity than quinine. The loading dose should be decreased or omitted in those patients who have received quinine or mefloquine. If more than 48 hours of parenteral treatment is required, the quinine or quinidine dose should be reduced by 1/3 to 1/2.
75. NJ White, N Engl J Med, 335:800, 1996.
76. Some relapses have been reported with this regimen, especially in strains from Southeast Asia; relapses should be treated with a second 14-day course of 30 mg base/day.
77. Primaquine phosphate can cause hemolytic anemia, especially in patients whose red cells are deficient in glucose-6-phosphate dehydrogenase. This deficiency is most common in African, Asian, and Mediterranean peoples. Patients should be screened for G-6-PD deficiency before treatment. Primaquine should not be used during pregnancy.
78. No drug regimen guarantees protection against malaria. If fever develops within a year (particularly within the first two months) after travel to malarious areas, travelers should be advised to seek medical attention. Insect repellents, insecticide-impregnated bed nets and proper clothing are important adjuncts for malaria prophylaxis.
79. In pregnancy, chloroquine prophylaxis has been used extensively and safely; the safety of other prophylactic antimalarial agents in pregnancy is less clear. Therefore, travel during pregnancy to chloroquine-resistant areas should be discouraged. See footnote 37.
80. For prevention of attack after departure from areas where P. vivax and P. ovale are endemic, which includes almost all areas where malaria is found (except Haiti), some experts prescribe in addition primaquine phosphate 15 mg base (26.3 mg)/d or, for children, 0.3 mg base/kg/d during the last two weeks of prophylaxis. Others prefer to avoid the toxicity of primaquine and rely on surveillance to detect cases when they occur, particularly when exposure was limited or doubtful. See also footnotes 54 and 55.
81. Beginning one week before travel and continuing weekly for the duration of stay and for four weeks after leaving.
82. The pediatric dosage has not been approved by the FDA, and the drug has not been approved for use during pregnancy. However, it has been reported to be safe for prophylactic use during the second half of pregnancy and possibly during early pregnancy as well (BL Smoak et al, J Infect Dis, 176:831, 1997). Women should take contraceptive precautions while taking mefloquine and for two months after the last dose. Mefloquine is not recommended for patients with cardiac conduction abnormalities. Patients with a history of seizures or psychiatric disorders should probably avoid mefloquine (Medical Letter, 32:13, 1990). Resistance to mefloquine has been reported in some areas, such as Thailand; in these areas, doxycycline should be used for prophylaxis. In children less than eight years old, proguanil plus sulfisoxazole has been used (KN Suh and JS Keystone, Infect Dis Clin Pract, 5:541, 1996).
83. The pediatric dosage has not been approved by the FDA, and the drug has not been approved for use during pregnancy. However, it has been reported to be safe for prophylactic use during the second half of pregnancy and possibly during early pregnancy as well (BL Smoak et al, J Infect Dis, 176:831, 1997). Women should take contraceptive precautions while taking mefloquine and for two months after the last dose. Mefloquine is not recommended for patients with cardiac conduction abnormalities. Patients with a history of seizures or psychiatric disorders should probably avoid mefloquine (Medical Letter, 32:13, 1990). Resistance to mefloquine has been reported in some areas, such as Thailand; in these areas, doxycycline should be used for prophylaxis. In children less than eight years old, proguanil plus sulfisoxazole has been used (KN Suh and JS Keystone, Infect Dis Clin Pract, 5:541, 1996).
84. The pediatric dosage has not been approved by the FDA, and the drug has not been approved for use during pregnancy. However, it has been reported to be safe for prophylactic use during the second half of pregnancy and possibly during early pregnancy as well (BL Smoak et al, J Infect Dis, 176:831, 1997). Women should take contraceptive precautions while taking mefloquine and for two months after the last dose. Mefloquine is not recommended for patients with cardiac conduction abnormalities. Patients with a history of seizures or psychiatric disorders should probably avoid mefloquine (Medical Letter, 32:13, 1990). Resistance to mefloquine has been reported in some areas, such as Thailand; in these areas, doxycycline should be used for prophylaxis. In children less than eight years old, proguanil plus sulfisoxazole has been used (KN Suh and JS Keystone, Infect Dis Clin Pract, 5:541, 1996).
85. Beginning one day before travel and continuing for the duration of stay and for four weeks after leaving. Use of tetracyclines is contraindicated in pregnancy and in children less than eight years old. Doxycycline can cause gastrointestinal disturbances, vaginal moniliasis and photosensitivity reactions.
86. Several studies have shown that daily primaquine provides effective prophylaxis against chloroquine-resistant P. falciparum (WR Weiss et al, J Infect Dis, 171:1569, 1995; DJ Fryauff et al, Lancet, 346:1190, 1995).
87. Several studies have shown that daily primaquine provides effective prophylaxis against chloroquine-resistant P. falciparum (WR Weiss et al, J Infect Dis, 171:1569, 1995; DJ Fryauff et al, Lancet, 346:1190, 1995).
88. In areas with strains resistant to pyrimethamine-sulfadoxine, atovaquone plus proguanil or doxycycline can also be used for presumptive treatment. See page 5 for dosage.
89. Proguanil (Paludrine - Wyeth Ayerst, Canada; Zeneca, England), which is not available in the USA but is widely available in Canada and overseas, is recommended mainly for use in Africa south of the Sahara. Prophylaxis is recommended during exposure and for four weeks afterwards. Proguanil has been used in pregnancy without evidence of toxicity (PA Phillips-Howard and D Wood, Drug Saf, 14:131, 1996).
90. Ocular lesions due to E. hellem in HIV-infected patients have responded to fumagillin eyedrops prepared from Fumidil-B, a commercial product (Mid-Continent Agrimarketing, Inc., Olathe, Kansas, 1-800-547-1392) used to control a microsporidial disease of honey bees (MC Diesenhouse, Am J Ophthalmol, 115:293, 1993). For lesions due to V. corneae, topical therapy is generally not effective and keratoplasty may be required (RM Davis et al, Ophthalmology, 97:953, 1990).
91. Ocular lesions due to E. hellem in HIV-infected patients have responded to fumagillin eyedrops prepared from Fumidil-B, a commercial product (Mid-Continent Agrimarketing, Inc., Olathe, Kansas, 1-800-547-1392) used to control a microsporidial disease of honey bees (MC Diesenhouse, Am J Ophthalmol, 115:293, 1993). For lesions due to V. corneae, topical therapy is generally not effective and keratoplasty may be required (RM Davis et al, Ophthalmology, 97:953, 1990).
92. Octreotide (Sandostatin) has provided symptomatic relief in some patients with large volume diarrhea. Oral fumagillin (see footnote 65) has been effective in treating E. bieneusi (J-M Molina et al, AIDS, 11:1603, 1997), but has been associated with thrombocytopenia.
93. J-M Molina et al, J Infect Dis, 171:245, 1995. There is no established treatment for Pleistophora.
94. Albendazole or pyrantel pamoate may be effective (HP Krepel et al, Trans R Soc Trop Med Hyg, 87:87, 1993).
95. 2 ≤ 70 mmHg or Aa gradient ≥ 35 mmHg, prednisone should also be used (S Gagnon et al, N Engl J Med, 323:1444, 1990; E Caumes et al, Clin Infect Dis, 18:319, 1994).
96. 2 ≤ 70 mmHg or Aa gradient ≥ 35 mmHg, prednisone should also be used (S Gagnon et al, N Engl J Med, 323:1444, 1990; E Caumes et al, Clin Infect Dis, 18:319, 1994).
97. Plus leucovorin 25 mg with each dose of pyrimethamine.
98. Oxamniquine has been effective in some areas in which praziquantel is less effective (FF Stelma et al, J Infect Dis, 176:304, 1997). Oxamniquine is contraindicated in pregnancy.
99. In East Africa, the dose should be increased to 30 mg/kg, and in Egypt and South Africa, 30 mg/kg/d × 2d. Some experts recommend 40-60 mg/kg over 2-3 days in all of Africa (KC Shekhar, Drugs, 42:379, 1991).
100. In immunocompromised patients or dissiminated disease, it may be necessary to prolong or repeat therapy or use other agents.
101. Ivermectin is not FDA-approved for disseminated strongyloidiasis, and thiabendazole may be preferred.
102. Some patients may benefit from or require surgical resection of cysts (RK Tompkins, Mayo Clin Proc, 66:1281, 1991). Praziquantel may be useful preoperatively or in case of spill during surgery.
103. Percutaneous drainage with ultrasound guidance plus albendazole therapy has been effective for management of hepatic hydatid cyst disease (MS Khuroo et al, N Engl J Med, 337:881, 1997).
104. Surgical excision is the only reliable means of treatment. Some reports have suggested use of albendazole or mebendazole (W Hao et al, Trans R Soc Trop Med Hyg, 88:340, 1994; WHO Group, Bull WHO, 74:231, 1996).
105. Surgical excision is the only reliable means of treatment. Some reports have suggested use of albendazole or mebendazole (W Hao et al, Trans R Soc Trop Med Hyg, 88:340, 1994; WHO Group, Bull WHO, 74:231, 1996).
106. Corticosteroids should be given for two to three days before and during drug therapy for neurocysticercosis. Any cysticercocidal drug may cause irreparable damage when used to treat ocular or spinal cysts, even when corticosteroids are used (AC White, Jr, Clin Infect Dis, 24:101, 1997). An ophthalmic exam should be done before treatment.
107. In ocular toxoplasmosis, corticosteroids should also be used for an anti-inflammatory effect on the eyes.
108. To treat CNS toxoplasmosis in HIV-infected patients, some clinicians have used pyrimethamine 50 to 100 mg daily after a loading dose of 200 mg with a sulfonamide and, when sulfonamide sensitivity developed, have given clindamycin 1.8 to 2.4 g/d in divided doses instead of the sulfonamide (JS Remington et al, Lancet, 338:1142, 1991; BJ Luft et al, N Engl J Med, 329:995, 1993). Atovaquone plus pyrimethamine appears to be an effective alternative in sulfa-intolerant patients (JA Kovacs et al, Lancet, 340:637, 1992). For primary prophylaxis in HIV patients with <100 CD4 cells, either trimethoprim-sulfamethoxazole, pyrimethamine plus dapsone or pyrimethamine plus sulfisoxazole can be used (USPHS/IDSA, Clin Infect Dis, 25 suppl 3:S313, 1997). Pyrimethamine plus folinic acid should be considered in HIV patients with <100 CD4 counts who are intolerant to trimethoprim-sulfamethoxazole (C Leport et al, J Infect Dis, 173:91, 1996).
109. To treat CNS toxoplasmosis in HIV-infected patients, some clinicians have used pyrimethamine 50 to 100 mg daily after a loading dose of 200 mg with a sulfonamide and, when sulfonamide sensitivity developed, have given clindamycin 1.8 to 2.4 g/d in divided doses instead of the sulfonamide (JS Remington et al, Lancet, 338:1142, 1991; BJ Luft et al, N Engl J Med, 329:995, 1993). Atovaquone plus pyrimethamine appears to be an effective alternative in sulfa-intolerant patients (JA Kovacs et al, Lancet, 340:637, 1992). For primary prophylaxis in HIV patients with <100 CD4 cells, either trimethoprim-sulfamethoxazole, pyrimethamine plus dapsone or pyrimethamine plus sulfisoxazole can be used (USPHS/IDSA, Clin Infect Dis, 25 suppl 3:S313, 1997). Pyrimethamine plus folinic acid should be considered in HIV patients with <100 CD4 counts who are intolerant to trimethoprim-sulfamethoxazole (C Leport et al, J Infect Dis, 173:91, 1996).
110. To treat CNS toxoplasmosis in HIV-infected patients, some clinicians have used pyrimethamine 50 to 100 mg daily after a loading dose of 200 mg with a sulfonamide and, when sulfonamide sensitivity developed, have given clindamycin 1.8 to 2.4 g/d in divided doses instead of the sulfonamide (JS Remington et al, Lancet, 338:1142, 1991; BJ Luft et al, N Engl J Med, 329:995, 1993). Atovaquone plus pyrimethamine appears to be an effective alternative in sulfa-intolerant patients (JA Kovacs et al, Lancet, 340:637, 1992). For primary prophylaxis in HIV patients with <100 CD4 cells, either trimethoprim-sulfamethoxazole, pyrimethamine plus dapsone or pyrimethamine plus sulfisoxazole can be used (USPHS/IDSA, Clin Infect Dis, 25 suppl 3:S313, 1997). Pyrimethamine plus folinic acid should be considered in HIV patients with <100 CD4 counts who are intolerant to trimethoprim-sulfamethoxazole (C Leport et al, J Infect Dis, 173:91, 1996).
111. To treat CNS toxoplasmosis in HIV-infected patients, some clinicians have used pyrimethamine 50 to 100 mg daily after a loading dose of 200 mg with a sulfonamide and, when sulfonamide sensitivity developed, have given clindamycin 1.8 to 2.4 g/d in divided doses instead of the sulfonamide (JS Remington et al, Lancet, 338:1142, 1991; BJ Luft et al, N Engl J Med, 329:995, 1993). Atovaquone plus pyrimethamine appears to be an effective alternative in sulfa-intolerant patients (JA Kovacs et al, Lancet, 340:637, 1992). For primary prophylaxis in HIV patients with <100 CD4 cells, either trimethoprim-sulfamethoxazole, pyrimethamine plus dapsone or pyrimethamine plus sulfisoxazole can be used (USPHS/IDSA, Clin Infect Dis, 25 suppl 3:S313, 1997). Pyrimethamine plus folinic acid should be considered in HIV patients with <100 CD4 counts who are intolerant to trimethoprim-sulfamethoxazole (C Leport et al, J Infect Dis, 173:91, 1996).
112. To treat CNS toxoplasmosis in HIV-infected patients, some clinicians have used pyrimethamine 50 to 100 mg daily after a loading dose of 200 mg with a sulfonamide and, when sulfonamide sensitivity developed, have given clindamycin 1.8 to 2.4 g/d in divided doses instead of the sulfonamide (JS Remington et al, Lancet, 338:1142, 1991; BJ Luft et al, N Engl J Med, 329:995, 1993). Atovaquone plus pyrimethamine appears to be an effective alternative in sulfa-intolerant patients (JA Kovacs et al, Lancet, 340:637, 1992). For primary prophylaxis in HIV patients with <100 CD4 cells, either trimethoprim-sulfamethoxazole, pyrimethamine plus dapsone or pyrimethamine plus sulfisoxazole can be used (USPHS/IDSA, Clin Infect Dis, 25 suppl 3:S313, 1997). Pyrimethamine plus folinic acid should be considered in HIV patients with <100 CD4 counts who are intolerant to trimethoprim-sulfamethoxazole (C Leport et al, J Infect Dis, 173:91, 1996).
113. Plus leucovorin 10 mg with each dose of pyrimethamine.
114. Congenitally infected newborns should be treated with pyrimethamine every two or three days and a sulfonamide daily for about one year (JS Remington and G Desmonts in JS Remington and JO Klein, eds, Infectious Disease of the Fetus and Newborn Infant, 4th ed, Philadelphia:Saunders, 1995, page 140).
115. For prophylactic use during pregnancy. If it is determined that transmission has occurred in utero, therapy with pyrimethamine and sulfadiazine should be started.
116. Albendazole or flubendazole (not available in the USA) may also be effective.
117. Sexual partners should be treated simultaneously. Metronidazole-resistant strains have been reported; higher doses of metronidazole for longer periods or use of tinidazole are sometimes effective against these strains (J Lossick, Rev Infect Dis, 12:3665, 1990). Desensitization has been recommended for patients allergic to metronidazole (MD Pearlman et al, Am J Obstet Gynecol, 174:934, 1996).
118. Sexual partners should be treated simultaneously. Metronidazole-resistant strains have been reported; higher doses of metronidazole for longer periods or use of tinidazole are sometimes effective against these strains (J Lossick, Rev Infect Dis, 12:3665, 1990). Desensitization has been recommended for patients allergic to metronidazole (MD Pearlman et al, Am J Obstet Gynecol, 174:934, 1996).
119. In heavy infection, it may be necessary to extend therapy to 3 days.
120. The addition of gamma interferon to nifurtimox for 20 days in a limited number of patients and in experimental animals appears to have shortened the acute phase of Chagas' disease (RE McCabe et al, J Infect Dis, 163:912, 1991).
121. Eflornithine is highly effective in T.b. gambiense and variably effective in T. b. rhodesiense infections, but remaining supply (only available from WHO) is very limited. Some clinicians have given 400 mg/kg/d IV in 4 divided doses for 14 days, followed by oral treatment with 300 mg/kg/d for 3-4 wks (F Milord et al, Lancet, 340:652, 1992).
122. In frail patients, begin with as little as 18 mg and increase the dose progressively. Pretreatment with suramin has been advocated for debilitated patients. Corticosteroids have been used to prevent arsenical encephalopathy (J Pepin et al, Trans R Soc Trop Med Hyg, 89:92, 1995).
123. For severe symptoms or eye involvement, corticosteroids can be used in addition.