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Antiparasitic Agents


In this chapter, antiparasitic therapy is organized into five categories: (1) agents active against luminal protozoans, (2) agents active against the kinetoplastid protozoans, (3) agents active against malarial parasites, (4) antibacterial agents with antiprotozoan activity, and (5) anthelmintics. These divisions are somewhat arbitrary because some drugs are pertinent to more than one category. Appendix 296.1 , which describes the drugs for parasitic infections, is arranged by organism. Appendix 296.2 provides the principal adverse effects of antiparasitic medications.

Appendix 296.1
Drugs for Parasitic Infections
From Kimberlin DW, et al, eds. Red Book: 2021–2024 Report of the Committee on Infectious Diseases . 32nd ed. Itasca: IL; American Academy of Pediatrics; 2021.
Disease Drug Adult Dosage Pediatric Dosage CDC Web Site, Including Listings of Adverse Events
African trypanosomiasis (African sleeping sickness) 1 www .cdc.gov/parasites/sleepingsickness/health_professionals/index.html
Trypanosoma brucei rhodesiense , hemolymphatic stage Suramin 1a 20 mg/kg (max 1 g), IV, on days 1, 3, 7, 14, and 21 2 10–20 mg/kg (max 1 g), IV, on days 1, 3, 7, 14, and 21 3
T. brucei rhodesiense , CNS involvement Melarsoprol 4 2.2 mg/kg/day (max 180–200 mg/day), IV, × 10 days 2.2 mg/kg/day (max 180–200 mg/day), IV, × 10 days
T. brucei gambiense , hemolymphatic stage Pentamidine 5 4 mg/kg/day, IV or IM, × 7–10 days 4 mg/kg/day, IV or IM, × 7–10 days
T. brucei gambiense , CNS involvement Nifurtimox + Eflornithine combination therapy 6 Nifurtimox 15 mg/kg/day orally in 3 doses × 10 days
PLUS
Eflornithine 400 mg/kg/day IV in two 2-h infusions (each dose diluted in 250 mL of water for injection) × 7 days. 7,8 		Nifurtimox 15 mg/kg/day orally in 3 doses × 10 days
PLUS
Eflornithine 400 mg/kg/day IV in two 2-h infusions (each dose diluted in 250 mL of water for injection) × 7 days. 9
American trypanosomiasis (Chagas disease; Trypanosoma cruzi infection) Benznidazole 10 2–12 years 5–7 mg/kg/day, orally, in 2 divided doses for 60 days www.cdc.gov/parasites/chagas/health_professionals/index.html
12 years or older 10a 5–7 mg/kg/day, orally, in 2 divided doses for 60 days
OR
Nifurtimox 1 Birth to <18 yr, 2.5 kg to <40 kg 10–20 mg/kg/day, orally, in 3 divided doses for 60 days
Birth to <18 years, ≥40 kg 8–10 mg/kg/day, orally, in 3 divided doses for 60 days
≥18 years 10b 8–10 mg/kg/day, orally, in 3 divided doses for 60 days
Ascariasis ( Ascaris lumbricoides; intestinal roundworm) Albendazole 11 400 mg, orally, once www.cdc.gov/parasites/ascariasis/health_professionals/index.html
OR
Mebendazole 12 100 mg, orally, twice daily for 3 days, or 500 mg, orally, once
OR
Ivermectin 13 150–200 μg/kg, orally, once
Babesiosis 14 Atovaquone 750 mg orally twice a day 40 mg/kg/day, orally, in 2 doses (max 750 mg/dose) www.cdc.gov/parasites/babesiosis/health_professionals/index.html
PLUS
Azithromycin On the first day, give a total dose in the range of 500–1000 mg, orally; on subsequent days, give a total daily dose in the range of 250–1000 mg 10 mg/kg (max 500 mg/dose), orally, on day 1, then 5 mg/kg/day (max 250 mg/dose), orally, on subsequent days
OR
Clindamycin 600 mg, orally, 3 times a day, or 300–600 mg, IV, 4 times a day 20–40 mg/kg/day (max 600 mg/dose), orally, in 3 doses
PLUS
Quinine 650 mg, orally, 3 times a day 30 mg/kg/day, orally, in 3 doses (max 650 mg/dose)
Balantidiasis ( Balantidium coli ) Tetracycline 500 mg, orally, 4 times daily for 10 days Age ≥8 years, 40 mg/kg/day (max 2 g), orally, in 4 doses for 10 days www.cdc.gov/parasites/balantidium/health_professionals/index.html
OR
Metronidazole 500–750 mg, orally, 3 times daily for 5 days 35–50 mg/kg/day, orally, in 3 doses for 5 days
OR
Iodoquinol 650 mg, orally, 3 times daily for 20 days 30–40 mg/kg/day (max 2 g), orally, in 3 doses for 20 days
OR
Nitazoxanide 500 mg, orally, twice daily for 3 days Age 4–11 years: 200 mg, orally, twice daily for 3 days
Age 1–3 years: 100 mg, orally, twice daily for 3 days
Baylisascariasis (raccoon roundworm infection) Albendazole 11 25–50 mg/kg/day, orally, for 10–20 days 15 www.cdc.gov/parasites/baylisascaris/health_professionals/index.html
Blastocystis hominis infection 16 Metronidazole 250 mg–750 mg, orally, 3 times daily for 10 days
Or 1500 mg once daily for 10 days		 35–50 mg/kg/day, orally, in 3 doses for 10 days www.cdc.gov/parasites/blastocystis/health_professionals/index.html
OR
Trimethoprim (TMP)/sulfamethoxazole (SMX) 160 mg TMP, 800 mg SMX twice daily for 7 days Age >2 months: 8 mg TMP/kg and 40 mg/kg SMX per day in 2 divided doses for 7 days
OR
Nitazoxanide 500 mg, orally, twice daily for 3 days Age 4–11 years: 200 mg, orally, twice daily for 3 days
Age 1–3 years: 100 mg, orally, twice daily for 3 days
Capillariasis Mebendazole 12 200 mg, orally, twice a day for 20 days www.cdc.gov/parasites/capillaria/health_professionals/index.html
OR
Albendazole 11 400 mg, orally, once a day for 10 days
Chilomastix mesnili infection No treatment is necessary; this protozoan is harmless www.cdc.gov/parasites/nonpathprotozoa/health_professionals/index.html
Clonorchiasis Praziquantel 75 mg/kg/day, orally, 3 doses/day for 2 days www.cdc.gov/parasites/clonorchis/health_professionals/index.html
OR
Albendazole 11 10 mg/kg/day for 7 days
Cutaneous larva migrans (zoonotic hookworm) Albendazole 11 400 mg/day, orally, once a day for 3–7 days Age >2 years: 400 mg/day, orally, for 3 days www.cdc.gov/parasites/zoonotichookworm/health_professionals/index.html
OR
Ivermectin 200 μg/kg, orally, as a single dose Weight >15 kg: 200 μg/kg, orally, as a single dose
Cyclosporiasis TMP/SMX 160 mg TMP/800 mg SMX, orally, 2 times/day × 7–10 days 8–10 mg TMP/kg/day, orally, divided 2 times/day for 7–10 days www.cdc.gov/parasites/cyclosporiasis/health_professionals/index.html
Cystoisosporiasis ( Cystoisospora infection; formerly isosporiasis) TMP/SMX 160 mg TMP/800 mg SMX, orally, 2 times/day × 7–10 days 8–10 mg TMP/kg/day, orally, divided 2 times/day for 7–10 days www.cdc.gov/parasites/cystoisospora/health_professionals/index.html
OR
Ciprofloxacin (second-line alternate) 500 mg, orally, 2 times/day × 7 days —
Dientamoeba fragilis infection Iodoquinol 650 mg, orally, 3 times/day for 20 days 30–40 mg/kg/day (max 2 g), orally, divided 3 times/day × 20 days www.cdc.gov/parasites/dientamoeba/health_professionals/index.html
OR
Paromomycin 25–35 mg/kg/day, orally, divided 3 times/day for 7 days
OR
Metronidazole 500–750 mg, orally, 3 times/day for 10 days 35–50 mg/kg/day, orally divided 3 times/day × 10 days
Diphyllobothrium infection Praziquantel 17 5–10 mg/kg, orally, in a single dose www.cdc.gov/parasites/dipyllobothrium/health_professionals/index.html
OR
Niclosamide 18 2 g, orally, once 50 mg/kg (max 2 g), orally, once
Dipylidium caninum infection (dog or cat flea tapeworm) Praziquantel 17 5–10 mg/kg, orally, in a single dose www.cdc.gov/parasites/dipylidium/health_professionals/index.html
OR
Niclosamide 18 2 g, orally, once 50 mg/kg, (max 2 g, orally, once)
Echinococcosis 19 Albendazole 11 400 mg, orally, twice a day for 1–6 months 10–15 mg/kg/day (max 800 mg), orally, in 2 doses for 1–6 months www.cdc.gov/parasites/echinococcosis/health_professionals/index.html
Endolimax nana infection No treatment is necessary; this protozoan is harmless www.cdc.gov/parasites/nonpathprotozoa/health_professionals/index.html
Entamoeba coli infection No treatment is necessary; this protozoan is harmless www.cdc.gov/parasites/nonpathprotozoa/health_professionals/index.html
Entamoeba dispar infection No treatment is necessary; this protozoan is harmless www.cdc.gov/parasites/nonpathprotozoa/health_professionals/index.html
Entamoeba hartmanni infection No treatment is necessary; this protozoan is harmless www.cdc.gov/parasites/nonpathprotozoa/health_professionals/index.html
Entamoeba polecki No treatment is necessary; this protozoan is harmless www.cdc.gov/parasites/nonpathprotozoa/health_professionals/index.html
Enterobiasis (pinworm) Mebendazole 12 100 mg, orally, once; repeat in 2 weeks www.cdc.gov/parasites/pinworm/health_professionals/index.html
OR
Pyrantel pamoate 11 mg/kg base, orally, once (max 1 g); repeat in 2 weeks
OR
Albendazole 11 For children 20 kg or greater: 400 mg PO once; repeat in 2 weeks
For children <20 kg: 200 mg PO once; repeat in 2 weeks
Fascioliasis ( Fasciola hepatica; sheep liver fluke) Triclabendazole 10 mg/kg, orally, twice, given 12 hours apart in patients ≥6 years www.cdc.gov/parasites/fasciola/health_professionals/index.html
OR
Nitazoxanide 500 mg, orally, 2 times/day × 7 days Age 1–3 years: 100 mg, orally, 2 times/day × 7 days
Age 4–11 years: 200 mg, orally, 2 times/day × 7 days
Age ≥12 years: 500 mg, orally, 2 times/day × 7 days
Fasciolopsiasis Praziquantel 17 75 mg/kg/day, orally, in 3 divided doses for 1 day www.cdc.gov/parasites/fasciolopsis/health_professionals/index.html
Gnathostomiasis (cutaneous) Albendazole 11 400 mg, orally, 2 times/day × 21 days www.cdc.gov/parasites/gnathostoma/health_professionals/index.html
OR
Ivermectin 13 200 μg, orally, once daily × 2 days
Heterophyiasis Praziquantel 17 75 mg/kg/day, divided 3 times/day × 1 day, orally www.cdc.gov/dpdxlheterophyiasis/tx.html
Hymenolepiasis ( Hymenolepis nana; dwarf tapeworm) Praziquantel 17 25 mg/kg in a single-dose therapy, orally www.cdc.gov/parasites/hymenolepis/health_professionals/index.html
OR
Niclosamide 18 2 g in a single dose for 7 days, orally Weight 11–34 kg: 1 g in a single dose on day 1, then 500 mg/day, orally, for 6 days
Weight >34 kg: 1.5 g in a single dose on day 1, then 1 g/day, orally, for 6 days
OR
Nitazoxanide 500 mg, orally, 2 times/day × 3 days Age 1–3 years: 100 mg, orally, 2 times/day × 3 days
Age 4–11 years: 200 mg, orally, 2 times/day × 3 days
Age ≥12 years: 500 mg, orally, 2 times/day × 3 days
Hookworm (Human; Ancylostoma duodenale, Necator americanus) Albendazole 11 400 mg, orally, once www.cdc.gov/parasites/hookworm/health_professionals/index.html
OR
Mebendazole 12 100 mg, orally, twice a day for 3 days, or 500 mg, orally, once
OR
Pyrantel pamoate 11 mg/kg (up to a maximum of 1 g), orally, daily for 3 days
Iodamoeba buetschlii Infection No treatment is necessary; this protozoan is harmless www.cdc.gov/parasites/nonpathprotozoa/health_professionals/index.html
Leishmaniasis 20
Visceral (Kala-azar) Liposomal amphotericin B 3 mg/kg/day, IV, on days 1–5, 14, and 21 (total dose of 21 mg/kg) www.cdc.gov/parasites/leishmaniasis/health_professionals/index.html
OR
Sodium stibogluconate 20 mg pentavalent antimony (Sb)/kg/day, IV or IM, × 28 days
OR
Miltefosine 30–44 kg: 50 mg, twice daily, for 28 consecutive days
≥45 kg: 50 mg, 3 times daily, for 28 consecutive days
OR
Amphotericin B deoxycholate 1 mg/kg, IV, daily × 15–20 days or every second day for up to 8 weeks (total usually 15–20 mg/kg)
Cutaneous Sodium stibogluconate 20 mg Sb/kg/day, IV or IM, × 20 days
OR
Miltefosine 30–44 kg: 50 mg, twice daily, for 28 consecutive days
≥45 kg: 50 mg, 3 times daily, for 28 consecutive days
Mucosal Sodium stibogluconate 20 mg Sb/kg/day, IV or IM, × 28 days
OR
Amphotericin B 0.5–1 mg/kg, IV, daily × 15–20 days or every second day for up to 8 weeks
OR
Miltefosine 30–44 kg: 50 mg, twice daily, for 28 consecutive days
≥45 kg: 50 mg, 3 times daily, for 28 consecutive days
Lice infestation (Pediculus humanus, P capitis, Phthirus pubis) 21 Pyrethrins with piperonyl butoxide 22 Topically, twice, at least 7 days apart Topically, twice at least 7 days apart www.cdc.gov/parasites/lice/body/health_professionals/index.html
www.cdc.gov/parasites/gnathostoma/health_professionals/index.html
www.cdc.gov/parasites/lice/pubic/health_professionals/index.html
OR
0.5% Ivermectin lotion 23 Topically, once Topically, once
OR
0.9% Spinosad suspension 24 Topically, twice, at least 7 days apart Topically, twice, at least 7 days apart
OR
1% Permethrin 22 Topically, twice, at least 7 days apart Topically, twice, at least 7 days apart
OR
5% Benzyl alcohol lotion 25 Topically, twice, at least 7 days apart Topically, twice, at least 7 days apart
OR
0.5% Malathion 26 Topically, twice, at least 7 days apart Topically, twice, at least 7 days apart
OR
Ivermectin 27 200 or 400 μg/kg, orally ≥15 kg: 200 or 400 μg/kg, orally
Loiasis (Loa loa) Indication: www.cdc.gov/parasites/loiasis/health_professionals/index.html
Symptomatic loiasis with microfilariae of L loa/mL <8000
Diethylcarbamazine (DEC) 28 8–10 mg/kg, orally, in 3 divided doses daily for 21 days
Indication:
Symptomatic loiasis, with microfilariae of L. loa/mL <8000 and failed 2 rounds DEC
OR
Symptomatic loiasis, with microfilariae of L. loa/mL ≥ 8000 to reduce level to <8000 prior to treatment with DEC
Albendazole 11 200 mg, orally, twice daily for 21 days
Lymphatic filariasis (elephantiasis; Wuchereria bancrofti, Brugia malayi, Brugia timori) Diethylcarbamazine (DEC) 28 Treatment of lymphatic filariasis:

  • Adults and children >18 months: 6 mg/kg/day, orally, divided into 3 doses for 12 consecutive days OR 6 mg/kg/day as a single oral dose

  • Treatment of tropical pulmonary eosinophilia:

Adults and children >18 months: 6 mg/kg/day, orally, divided into 3 doses for 14–21 days

 www.cdc.gov/parasites/lymphaticfilariasis/health_professionals/index.html
Malaria (Plasmodium species) Region infection acquired https://www.cdc.gov/malaria/resources/pdf/Malaria_Treatment_Table.pdf
Uncomplicated malaria P. falciparum or species not identified
If “species not identified” subsequently diagnosed as P vivax or P ovale, see below re: treatment with primaquine or tafenoquine		 Chloroquine-resistant or unknown resistance 29,30
(All malarious regions except those specified as chloroquine-sensitive listed below.)		 CDC Malaria Hotline: (770) 488-7788 or (855) 856-4713 toll-free Monday-Friday 9 am to 5 pm EST; (770) 488-7100 after hours, weekends, and holidays
Artemether-lumefantrine 31,32
1 tablet = 20 mg artemether and 120 mg lumefantrine		 A 3-day treatment schedule with a total of 6 oral doses is recommended for both adult and pediatric patients based on weight. The patient should receive the initial dose, followed by the second dose 8 h later, then 1 dose, orally, 2 times/day, for the following 2 days.
4 tablets/does 5 to <15 kg: 1 tablet/dose
15 to <25 kg: 2 tablets/dose
25 to <35 kg: 3 tablets/dose
≥35 kg: 4 tablets/dose
OR
Atovaquone-proguanil 31,33
Adult tablet = 250 mg atovaquone/100 mg proguanilPediatric tablet = 62.5 mg atovaquone/25 mg proguanil		 4 adult tabs (1000 mg atovaquone/400 mg proguanil), orally, once daily × 3 days 5–<8 kg: 2 pediatric tablets, orally, once daily × 3 days
8–<10 kg: 3 pediatric tablets, orally, once daily × 3 days
10–<20 kg: 1 adult tablets, orally, once daily × 3 days
20–<30 kg: 2 adult tablets, orally, once daily × 3 days
30–<40 kg: 3 adult tablets, orally, once daily × 3 days
≥40 kg: 4 adult tablets, orally, once daily × 3 days
OR
Quinine sulfate 34,35 plus one of the following: Doxycycline, 36 Tetracycline, 36 or Clindamycin 36 Quinine sulfate: 542 mg base (=650 mg salt), 34 orally, 3 times/day × 3 or 7 days 35 Quinine sulfate: 8.3 mg base/kg (=10 mg salt/kg), orally, 3 times/day × 3 or 7 days
Doxycycline: 100 mg, orally, 2 times/day × 7 days Doxycycline: 2.2 mg/kg, orally, every 12 h × 7 days
Tetracycline: 250 mg, orally, 4 times/day × 7 days Tetracycline: 25 mg/kg/day, orally, divided 4 times/day × 7 days
Clindamycin: 20 mg base/kg/day, orally, divided 3 times/day × 7 days Clindamycin: 20 mg base/kg/day, orally, divided 3 times/day × 7 days
OR
Mefloquine Mefloquine 37 684 mg base (=750 mg salt), orally, as initial dose, followed by 456 mg base (=500 mg salt), orally, given 6–12 h after initial dose
Total dose = 1250 mg salt		 Mefloquine: 13.7 mg base/kg (=15 mg salt/kg), orally, as initial dose, followed by 9.1 mg base/kg (=10 mg salt/kg), orally, given 6–12 h after initial dose
Total dose = 25 mg salt/kg
Uncomplicated malaria Chloroquine-sensitive
P. falciparum or species not identified (Central America west of Panama Canal; Haiti; the Dominican Republic; and most of the Middle East)
Chloroquine phosphate 38 600 mg base (=1000 mg salt), orally, immediately, followed by 300 mg base (=500 mg salt), orally, at 6, 24, and 48 h
Total dose: 1500 mg base (=2500 mg salt)		 10 mg base/kg, orally, immediately, followed by 5 mg base/kg, orally, at 6, 24, and 48 h
Total dose: 25 mg base/kg
OR
Hydroxychloroquine 620 mg base (=800 mg salt), orally, immediately, followed by 310 mg base (=400 mg salt), orally, at 6, 24, and 48 h
Total dose: 1550 mg base (=2000 mg salt)		 10 mg base/kg, orally, immediately, followed by 5 mg base/kg, orally, at 6, 24, and 48 h
Total dose: 25 mg base/kg
Uncomplicated malaria All regions
P malariae or P knowlesi Chloroquine phosphate 38 600 mg base (=1000 mg salt), orally, immediately, followed by 300 mg base (=500 mg salt), orally, at 6, 24, and 48 h
Total dose: 1500 mg base (=2500 mg salt)		 10 mg base/kg, orally, immediately, followed by 5 mg base/kg, orally, at 6, 24, and 48 h
Total dose: 25 mg base/kg
OR
Hydroxychloroquine 620 mg base (=800 mg salt), orally, immediately, followed by 310 mg base (=400 mg salt), orally, at 6, 24, and 48 h
Total dose: 1550 mg base (=2000 mg salt)		 10 mg base/kg, orally, immediately, followed by 5 mg base/kg, orally, at 6, 24, and 48 h
Total dose: 25 mg base/kg
Uncomplicated malaria All regions
P. vivax or P. ovale Note: for suspected chloroquine-resistant P. vivax, see row below
Chloroquine phosphate PLUS either primaquine phosphate or tafenoquine 38,39 Chloroquine phosphate: 600 mg base (=1000 mg salt), orally, immediately, followed by 300 mg base (=500 mg salt), orally, at 6, 24, and 48 h; Total dose: 1500 mg base (=2500 mg salt) Chloroquine phosphate: 10 mg base/kg, orally, immediately, followed by 5 mg base/kg, orally, at 6, 24, and 48 h; Total dose: 25 mg base/kg
Primaquine phosphate: 30 mg base, orally, once daily × 14 days Primaquine phosphate: 0.5 mg base/kg, orally, once daily × 14 days
Tafenoquine: 300 mg orally 1 dose Tafenoquine (only ≥16 years): 300 mg orally, 1 dose
OR
Hydroxychloroquine PLUS either Primaquine phosphate or Tafenoquine 38, 39 620 mg base (=800 mg salt), orally, immediately, followed by 310 mg base (=400 mg salt), orally, at 6, 24, and 48 h
Total dose: 1550 mg base (=2000 mg salt)		 10 mg base/kg, orally, immediately, followed by 5 mg base/kg, orally, at 6, 24, and 48 h
Total dose: 25 mg base/kg
Primaquine phosphate: 30 mg base, orally, once daily × 14 days Primaquine phosphate: 0.5 mg base/kg, orally, once daily × 14 days
Tafenoquine: 300 mg orally 1 dose Tafenoquine (only in children ≥16 years): 300 mg orally, 1 dose
Uncomplicated malaria Chloroquine-resistant 40 (Papua New Guinea and Indonesia)
P. vivax Artemether-lumefantrine 31 plus Primaquine phosphate 39 Artemether-lumefantrine: A 3-day treatment schedule with a total of 6 oral doses is recommended for both adult and pediatric patients based on weight. The patient should receive the initial dose, followed by the second dose 8 h later, then 1 dose, orally, 2 times/day, for the following 2 days. Each tablet consists of 20 mg artemether and 120 mg lumefantrine.
5–<15 kg: 1 tablet/dose
15–<25 kg: 2 tablets/dose
25–<35 kg: 3 tablets/dose
≥35 kg: 4 tablets/dose
Primaquine phosphate: 30 mg base, orally, once daily × 14 days Primaquine phosphate: 0.5 mg base/kg, orally, once daily × 14 days
OR
Atovaquone-proguanil plus Primaquine phosphate 39 Atovaquone-proguanil: 4 adult tablets (1000 mg atovaquone/400 mg proguanil), orally, once daily × 3 days Atovaquone-proguanil:
5–<8 kg: 2 pediatric tablets, orally, once daily × 3 days
8–<10 kg: 3 pediatric tablets, orally, once daily × 3 days
10–<20 kg: 1 adult tablets, orally, once daily × 3 days
20–<30 kg: 2 adult tablets, orally, once daily × 3 days
30–<40 kg: 3 adult tablets, orally, once daily × 3 days
≥40 kg: 4 adult tablets, orally, once daily × 3 days
Primaquine phosphate: 30 mg base, orally, once daily × 14 days Primaquine phosphate: 0.5 mg base/kg, orally, once daily × 14 days
OR
Quinine sulfate plus either, Doxycycline, Tetracycline or Clindamycin 36 plus Primaquine phosphate 39 Quinine sulfate: 542 mg base (=650 mg salt),4 orally, 3 times/day × 3 or 7 days 35 Quinine sulfate: 8.3 mg base/kg (=10 mg salt/kg), orally, 3 times/day × 3 or 7 days 35
Doxycycline: 100 mg, orally, 2 times/day × 7 days Doxycycline: 2.2 mg/kg, orally, every 12 h × 7 days
Tetracycline: 250 mg, orally, 4 times/day × 7 days Tetracycline: 25 mg/kg/day, orally, divided 4 times/day × 7 days
Clindamycin: 20 mg base/kg/day, orally, divided 3 times/day × 7 days Clindamycin: 20 mg base/kg/day, orally, divided 3 times/day × 7 days
Primaquine phosphate: 30 mg base, orally, once daily × 14 days Primaquine phosphate: 0.5 mg base/kg, orally, once daily × 14 days
OR
Mefloquine plus Primaquine phosphate 39 Mefloquine: 684 mg base (=750 mg salt), orally, as initial dose, followed by 456 mg base (=500 mg salt), orally, given 6–12 h after initial dose
Total dose = 1250 mg salt		 Mefloquine: 13.7 mg base/kg (=15 mg salt/kg), orally, as initial dose, followed by 9.1 mg base/kg (=10 mg salt/ kg), orally, given 6–12 h after initial dose
Total dose = 25 mg salt/kg
Primaquine phosphate: 30 mg base, orally, once daily × 14 days Primaquine phosphate: 0.5 mg base/kg, orally, once daily × 14 days
Uncomplicated malaria: alternatives for pregnant women 41,42 Chloroquine-sensitive
(see uncomplicated malaria sections above for chloroquine-sensitive species by region)
Chloroquine phosphate 38 600 mg base (=1000 mg salt), orally, immediately, followed by 300 mg base (=500 mg salt), orally, at 6, 24, and 48 h Not applicable
Total dose: 1500 mg base (=2500 mg salt)
OR
Hydroxychloroquine 620 mg base (=800 mg salt), orally, immediately, followed by 310 mg base (=400 mg salt), orally, at 6, 24, and 48 h Not applicable
Total dose: 1550 mg base (=2000 mg salt)
Chloroquine-resistant
(see sections above for regions with chloroquine resistant P. falciparum and P. vivax)
Artemether-lumefantrine 31,32
1 tablet = 20 mg artemether and 120 mg lumefantrine (second or third trimesters)		 A 3-day treatment schedule with a total of 6 oral doses based on weight. The patient should receive the initial dose, followed by the second dose 8 h later, then 1 dose, orally, 2 times/day, for the following 2 days. Not applicable
15–<25 kg: 2 tablets/dose
25–<35 kg: 3 tablets/dose
≥35 kg: 4 tablets/dose
OR
Quinine sulfate plus Clindamycin
(all trimesters)		 Quinine sulfate: 542 mg base (=650 mg salt), 34 orally, 3 times/day × 3 or 7 days 35 Not applicable
Clindamycin: 20 mg base/kg/day, orally, divided 3 times/day × 7 days
OR
Mefloquine (all trimesters) 684 mg base (=750 mg salt), orally, as initial dose, followed by 456 mg base (=500 mg salt), orally, given 6–12 h after initial dose Not applicable
Total dose =1250 mg salt
Severe malaria 43,44 All regions
IV artesunate: Commercially available. 1 dose=2.4 mg/kg
IV doses (3 in total) at 0, 12 and 24 h
PLUS reassessment and follow-on treatment below
If IV artesunate not readily available, give oral antimalarials while obtaining IV artesunate . When IV artesunate arrives, discontinue oral antimalarial and initiate IV treatment. Interim treatment options (dosed as above):

  • Artemether-lumefantrine (preferred); or

  • Atovaquone-proguanil; or

  • Quinine sulfate; or

  • Mefloquine (only if no other options available)

If oral therapy not tolerated, consider administration via nasogastric (NG) tube or after an antiemetic.
Reassessment and follow-on treatment:
Reassess parasite density at least 4 h after the third dose.
Parasite density ≤1% and patient able to tolerate oral medications: Give a complete follow-on oral regimen. Options include (dosed as above):

  • Artemether-lumefantrine (preferred), or

  • Atovaquone-proguanil, or

  • Quinine plus doxycycline or, in children <8 years old and pregnant women, clindamycin, or

  • Mefloquine (only if no other options available)

Parasite density >1%: Continue IV artesunate, same dose, QD up to 6 more days until parasite density ≤1%. When parasite density ≤1%, give complete follow-on oral regimen as listed above.
Parasite density ≤1% but patient unable to take oral medication: Continue IV artesunate, same dose, QD up to 6 more days until patient able to take oral therapy.
Neurocysticercosis 45 Albendazole 11 For treatment of 1–2 viable intraparenchymal cysts or in patients with a single enhancing lesion: 15 mg/kg/day (max 1200 mg/day), orally, in 2 divided doses for 10–14 days (take with food); expert consultation advised
For treatment of >2 viable parenchymal cysts: Albendazole 15 mg/kg/day combined with praziquantel 50 mg/kg/day for 10–14 days; expert consultation advised		 www.cdc.gov/parasites/cysticercosis/health_professionals/index.html
AND (if two or more viable intraparenchymal central nervous system cycsticerci) 45
Praziquantel 17 50 mg/kg/day, orally, for 10–14 days
Onchocerciasis ( Onchocerca volvulus; River Blindness) 46 IvermectinORDoxycycline 47 150 μg/kg, orally, in 1 dose every 6 months until asymptomatic
200 mg, orally, daily for 6 weeks		 www.cdc.gov/parasites/onchocerciasis/health_professionals/index.html
Opisthorchis Infection (Southeast Asian liver fluke) Praziquantel 17 75 mg/kg/day, orally, divided 3 times/day for 2 days www.cdc.gov/parasites/opisthorchis/health_professionals/index.html
OR
Albendazole 11 10 mg/kg/day, orally, for 7 days
Paragonimiasis Praziquantel 17 75 mg/kg/day, orally, divided 3 times/day for 2 days www.cdc.gov/parasites/paragonimus/health_professionals/index.html
OR
Triclabendazole 10 mg/kg/dose, orally, twice, given 12 hours apart in patients ≥6 years
Scabies (Mite Infestation) Permethrin cream 5% Topically, twice, at least 7 days apart www.cdc.gov/parasites/scabies/health_professionals/meds.html
OR
Crotamiton lotion 10% and Crotamiton cream 10% Topically, overnight, on days 1, 2, 3, and 8
OR
Ivermectin 200 μg/kg, orally, twice, at least 7 days apart
Schistosomiasis (Bilharzia) Schistosoma mansoni, S. haematobium, S. intercalatum www.cdc.gov/parasites/schistosomiasis/health_professionals/index.html
Praziquantel 17 40 mg/kg/day, orally, divided 2 times/day for 1 day
S. japonicum, S. mekongi
Praziquantel 17 60 mg/kg/day, orally, divided 3 times/day for 1 day
Strongyloidiasis Ivermectin 200 μg/kg, orally, daily for 1–2 days; for patients unable to take ivermectin orally, a parenteral formulation is available commercially for veterinary use and used under a single patient investigational new drug application on request to FDA www.cdc.gov/parasites/strongyloides/health_professionals/index.html
OR
Albendazole 11 400 mg, orally, divided 2 times/day for 7 days
Taeniasis [Taenia saginata (beef tapeworm), Taenia solium (pork tapeworm), and Taenia asiatica (Asian tapeworm)] Praziquantel 17 5–10 mg/kg, orally, once www.cdc.gov/parasites/taeniasis/health_professionals/index.html
OR
Niclosamide 18 2 g, orally, once 50 mg/kg, orally, once
Toxocariasis (Ocular Larva Migrans, Visceral Larva Migrans) Albendazole 11 400 mg, orally, 2 times/day × 5 days www.cdc.gov/parasites/toxocariasis/health_professionals/index.html
OR
Mebendazole 12 100–200 mg, orally, 2 times/day × 5 days
Toxoplasmosis CNS disease ( Toxoplasma gondii ) 48 Pyrimethamine 49 200 mg, orally, once, then 50–75 mg/day, orally × 3–6 weeks 2 mg/kg/day, orally, × 2 days, then 1 mg/kg/day (max 25 mg/day) × 3–6 weeks www.cdc.gov/parasites/toxoplasmosis/health_professionals/index.html
PLUS
Sulfadiazine 1.5 g, orally, 4 times/day × 3–6 weeks 100–200 mg/kg/day, 6 h × 3–6 weeks
OR
Pyrimethamine 49 200 mg, orally, once, then 50–75 mg/day, orally, × 3–6 weeks 2 mg/kg/day, orally, × 2 days, then 1 mg/kg/day (max 25 mg/day) × 3–6 weeks
PLUS
Clindamycin 1.8–2.4 g/day, IV or orally, divided 3 or 4 times/day × 3–6 weeks 5–7.5 mg/kg/dose (max 600 mg/ dose), orally, divided 3 or 4 times/day × 3–6 weeks
OR
Pyrimethamine 49 200 mg, orally, once, then 50–75 mg/day, orally, × 3–6 weeks 2 mg/kg/day, orally, × 2 days, then 1 mg/kg/day (max 25 mg/day) × 3–6 weeks
PLUS
Atovaquone 1500 mg, orally, 2 times/day See footnote 48.
OR
Trimethoprim/Sulfamethoxazole 15–20 mg/kg TMP and 75–100 mg/kg SMX/day divided 3 or 4 times/day × 3–6 weeks 15–20 mg/kg TMP and 75–100 mg/kg SMX per day divided 3 or 4 times/day × 3–6 weeks
Toxoplasmosis in pregnancy and neonates ( Toxoplasma gondii ) See footnote 50 . www.cdc.gov/parasites/toxoplasmosis/health_professionals/index.html
Trichinellosis (trichinosis; Trichinella species) Albendazole 11 400 mg, orally, twice a day for 8–14 days www.cdc.gov/parasites/trichinellosis/health_professionals/index.html
OR
Mebendazole 12 200–400 mg, orally, 3 times a day for 3 days, then 400–500 mg, orally, 3 times a day for 10 days
Trichuriasis (whipworm infection; Trichuris trichiura) Albendazole 11 400 mg, orally, for 3 days www.cdc.gov/parasites/whipworm/health_professionals/index.html
OR
Mebendazole 12 100 mg, orally, twice a day for 3 days
OR
Ivermectin 200 μg/kg/day, orally, for 3 days

CDC, Centers for Disease Control and Prevention; IV, intravenous; CNS, central nervous system; IM, intramuscular; FDA, US Food and Drug Administration.

1 Fexinidazole is FDA-approved with anticipated commercial availability in 2022. Once fexinidazole is commercially available in the US, treatment approaches for certain individuals with T .b. gambiense may be modified. Expert consultation is advised.

1a Pentamidine also is effective against T. brucei rhodesiense in the hemolymphatic stage, but suramin may have somewhat higher efficacy. Suramin is not approved by the FDA but is available through the CDC Drug Service.

2 A suramin test dose of 4–5 mg/kg should be given prior to the first dose, and the patient should be monitored for hemodynamic stability.

3 A suramin test dose of 2 mg/kg (max 100 mg) should be given prior to the first dose, and the patient should be monitored for hemodynamic stability.

4 Corticosteroids have been used to prevent melarsoprol encephalopathy. Melarsoprol is not approved by the FDA but is available through the CDC Drug Service.

5 Suramin also is effective against T. brucei gambiense in the hemolymphatic stage but should be used only in patients in whom onchocerciasis has been excluded. Suramin is not approved by the FDA but is available through the CDC Drug Service.

6 Eflornithine (400 mg/kg/day, IV, in 2 doses × 7 days) given in combination with oral nifurtimox (15 mg/kg/day, in 3 divided doses × 10 days) is also highly effective against T. brucei gambiense with CNS involvement; Eflornithine is not approved by the FDA but is available through the CDC Drug Service.

7 Alternative nifurtimox plus eflornithine combination therapy (10 days of nifurtimox 15m/kg/day orally in three doses and eflornithine 400 mg/kg/day intravenously in four 2-hour infusions [each dose diluted in 100 mL of water for injection] × 14 days).

8 Treatment for relapse is with melarsoprol 2.2 mg/kg/day intravenously × 10 days.

9 Eflornithine in children weighing <10 kg: dilute in 50 mL of water for injection. Children weighing 10–25 kg: dilute in 100 mL of water for injection. If water for injection is unavailable, eflornithine can be diluted in 5% dextrose or saline.

10 The 2 drugs used to treat infection with Trypanosoma cruzi are benznidazole and nifurtimox. For both drugs, adverse effects are fairly common and tend to be more frequent and more severe with increasing age. Questions regarding treatment should be directed to Parasitic Diseases Public Inquiries (404-718-4745; e-mail parasites@cdc.gov ).

10a Use of benznidazole to treat a patient outside of the FDA-approved age range of 2–12 years is based on clinical diagnosis and decision by a treating physician under practice of medicine.

10b Use of nifurtimox to treat a patient outside of the FDA-approved age range of birth to younger than 18 years is based on clinical diagnosis and decision by a treating physician under practice of medicine.

11 The safety of albendazole in children younger than 6 years is not certain. Studies of the use of albendazole in children as young as 1 year suggest that its use is safe.

12 The safety of mebendazole in children has not been established. There are limited data in children 2 years and younger.

13 Safety of ivermectin for treating children who weigh <15 kg has not been established.

14 Usually treat for at least 7–10 days. The combination of clindamycin plus quinine is the standard of care for babesiosis patients who are severely ill.

15 In cases in which suspicion of exposure is high, immediate treatment with albendazole (25–50 mg/kg/day by mouth for 10–20 days) may be appropriate. Treatment is successful when administered soon after exposure to abort the migration of larvae. Treatment should be initiated as soon as possible after ingestion of infectious material, ideally within 3 days. For clinical baylisascariasis, treatment with albendazole with concurrent corticosteroids to help reduce the inflammatory reaction is indicated to attempt to control the disease.

16 The clinical significance of Blastocystis species is controversial.

17 Praziquantel is not approved for treatment of children younger than 4 years, but this drug has been used successfully to treat cases of D. caninum infection in children as young as 6 months.

18 Niclosamide is not available in the US.

19 Treatment of cystic echinococcosis depends on the World Health Organization classification of the cysts. Albendazole is not appropriate for all forms of the infection. Expert consultation is advised.

20 Sodium stibogluconate is no longer available. Expert consultation about potential treatment options for leishmaniasis is encouraged. For some cases of cutaneous leishmaniasis, no therapy may be needed, or local (vs systemic) therapy may suffice, or other systemic treatments may be considered. Miltefosine was approved in 2014 by the FDA for treatment of visceral leishmaniasis attributable to L. donovani, mucosal leishmaniasis attributable to L. braziliensis, and cutaneous leishmaniasis attributable to L. braziliensis, L. guyanensis, and L. panamensis for patients who are at least 12 years of age and at least 30 kg of weight.

21 Pediculicides should not be used for infestations of the eyelashes. Such infestations are treated with petrolatum ointment applied 2–4 times/day for 8–10 days. For pubic lice, treat with 1% permethrin, pyrethrins with piperonyl butoxide, or ivermectin.

22 Permethrin and pyrethrin are pediculicidal; retreatment in 7–10 days is needed to eradicate the infestation. Some lice are resistant to pyrethrins and permethrin. Pyrethrins with piperonyl butoxide are recommended for use in children >2 years old; permethrin for children >2 months old.

23 Ivermectin is not ovicidal, but lice that hatch from treated eggs die within 48 hours after hatching. Recommended for use in children >6 months old.

24 Spinosad is not ovicidal but causes neuronal excitation in insects leading to paralysis and death. The formulation also includes benzyl alcohol, which is pediculicidal. Two applications 7 days apart are needed. Recommended for children >4 years old.

25 Benzyl alcohol prevents lice from closing their respiratory spiracles, and the lotion vehicle then obstructs their airway causing them to asphyxiate. It is not ovicidal. Two applications at least 7 days apart are needed. Recommended for use in children >6 months old. Resistance, which is a problem with other drugs, is unlikely to develop.

26 Malathion is both ovicidal and pediculicidal; 2 applications at least 7 days apart are generally necessary to kill all lice and nits. Recommended for children >6 years old.

27 Ivermectin is pediculicidal, but not ovicidal; >1 dose is generally necessary to eradicate the infestation. The number of doses and interval between doses has not been established; animal studies have shown adverse effects on the fetus. In one study of treatment of head lice, 2 doses of ivermectin (400 μg/kg) 7 days apart were more effective than treatment with topical malathion. In one study of treatment of body lice, a regimen of 3 doses of ivermectin (12 mg each) administered at 7-day intervals was effective.

28 Diethylcarbamazine (DEC) is not approved by the FDA but is available from the CDC Drug Service through an IND after confirmed positive lab results. DEC is contraindicated in patients who may also have onchocerciasis. Prior to DEC treatment for lymphatic filariasis, onchocerciasis should be excluded in all patients with a consistent exposure history because of the possibility of severe exacerbations of skin and eye involvement (Mazzotti reaction). People coinfected with loiasis and O volvulus should not be treated with DEC until the onchocerciasis is treated; their onchocerciasis should not be treated with ivermectin if it is unsafe to treat their loiasis.

29 If a person develops malaria despite taking chemoprophylaxis, that particular medicine should not be used as a part of their treatment regimen. Use one of the other options instead.

30 There are 4 options available for treatment of uncomplicated malaria caused by chloroquine-resistant P falciparum. The first three options are equally recommended. Because of a higher rate of severe neuropsychiatric reactions seen at treatment doses, mefloquine is not recommended unless the other options cannot be used. For quinine, because there are more data on the efficacy of quinine in combination with doxycycline or tetracycline, these treatment combinations are generally preferred to quinine in combination with clindamycin.

31 Atovaquone-proguanil or artemether-lumefantrine should be taken with food or whole milk. If patient vomits within 30 minutes of taking a dose, the dose should be repeated.

32 Artemether-lumefantrine can be used in second and third trimesters of pregnancy and, if no other options are available, in first trimester as well. Not for infants <5 kg and women breastfeeding infants <5 kg.

33 Atovaquone-proguanil is not recommended during pregnancy, in infants <5 kg, or in women breastfeeding infants <5 kg. May be considered if other treatment options are not available or not tolerated, and benefits outweigh risks.

34 The US-manufactured quinine sulfate capsule is in a 324-mg dosage; therefore, 2 capsules should be sufficient for adult dosing. Pediatric dosing may be difficult because of unavailability of noncapsule forms of quinine.

35 For infections acquired in Southeast Asia, quinine treatment should continue for 7 days. For infections acquired elsewhere, quinine treatment should continue for 3 days.

36 Doxycycline or tetracycline combined with quinine are preferred over clindamycin due to more efficacy data but are not recommended during pregnancy or in children <8 years old unless no other options and benefits outweigh risks. For children younger than 8 years with chloroquine-resistant P falciparum, atovaquone-proguanil and artemether-lumefantrine are recommended treatment options; mefloquine can be considered if no other options are available.

37 Treatment with mefloquine is not recommended if other options are available. Mefloquine is not recommended in people who have acquired infections from Southeast Asia because of drug resistance, or in patients with neuropsychiatric history.

38 When treating chloroquine-sensitive infections, chloroquine and hydroxychloroquine are recommended options. However, regimens used to treat chloroquine-resistant infections may also be used if available, more convenient, or preferred.

39 Primaquine and tafenoquine (Krintafel only) are used to eradicate any hypnozoites that may remain dormant in the liver and, thus, prevent relapses in P. vivax and P. ovale infections. Tafenoquine can only be used for antirelapse treatment if chloroquine or hydroxychloroquine used for acute treatment due to limited data on efficacy when in combination with other regimens. Primaquine and tafenoquine are associated with hemolytic anemia in those with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Prior to use, quantitative G6PD testing is needed to confirm normal activity. For those with intermediate G6PD deficiency, weekly primaquine may be used (45 mg/week) for 8 weeks with close monitoring for hemolysis. Those with G6PD deficiency may be given chloroquine 300 mg (base) po weekly for 1 year from acute infection to prevent relapses. In patients ≥70 kg, adjust to total dose 6 mg/kg, given in daily doses of 30 mg/day times the number of days to complete the total dose. Primaquine and tafenoquine must not be used during pregnancy; pregnant patients with P. vivax and P. ovale infections should receive chloroquine 300 mg (base) po weekly after acute treatment for the remainder of pregnancy. After delivery, patients with normal G6PD activity can be given primaquine or tafenoquine depending on breastfeeding or continue with chloroquine prophylaxis for a total of 1 year from acute infection. Primaquine can be used during breastfeeding if the infant is found to have normal G6PD activity; tafenoquine is not recommended during breastfeeding.

40 There are 4 options available for treatment of uncomplicated malaria caused by chloroquine-resistant P vivax. High treatment failure rates attributable to chloroquine-resistant P. vivax have been well documented in Papua New Guinea and Indonesia. Rare case reports of chloroquine-resistant P vivax have also been documented in Burma (Myanmar), India, and Central and South America. People acquiring P vivax infections outside of Papua New Guinea or Indonesia should be started on chloroquine. If the patient does not respond, the treatment should be changed to a chloroquine-resistant P vivax regimen and the CDC should be notified (Malaria Hotline number listed previously). For treatment of chloroquine-resistant P vivax infections, the first three options are equally recommended; mefloquine should be used only if no other options are available.

41 For pregnant women diagnosed with uncomplicated malaria caused by chloroquine-resistant P. falciparum or chloroquine-resistant P. vivax infection, treatment with doxycycline or tetracycline is generally not indicated. However, doxycycline or tetracycline may be used in combination with quinine (as recommended for nonpregnant adults) if other treatment options are not available or are not being tolerated, and the benefit is judged to outweigh the risks.

42 For P. vivax and P. ovale infections, primaquine phosphate for radical treatment of hypnozoites should not be given during pregnancy. Pregnant patients with P. vivax and P. ovale infections should be maintained on chloroquine prophylaxis for the duration of their pregnancy. The chemoprophylactic dose of chloroquine phosphate is 300 mg base (=500 mg salt), orally, once per week. After delivery, pregnant patients who do not have G6PD deficiency should be treated with primaquine.

43 People with a positive blood smear OR history of recent possible exposure and no other recognized pathologic abnormality who have 1 or more of the following clinical criteria (impaired consciousness/coma, severe normocytic anemia, renal failure, pulmonary edema, acute respiratory distress syndrome, circulatory shock, disseminated intravascular coagulation, spontaneous bleeding, acidosis, hemoglobinuria, jaundice, repeated generalized convulsions, and/or parasitemia of >5%) are considered to have manifestations of more severe disease. Severe malaria is most often caused by P falciparum.

44 Pregnant women diagnosed with severe malaria should be treated aggressively with parenteral antimalarial therapy.

45 Albendazole is currently the treatment of choice for neurocysticercosis. Albendazole combined with praziquantel is recommended when there are more than two viable intraparenchymal central nervous system cysticerci. Steroids are almost always required when albendazole and/or praziquantel is used. Not all forms of neurocysticercosis should be treated with anthelmintics. Some forms should only be treated with surgery. Some forms require only symptom control. Longer courses of antiparasitic and anti-inflammatory agents may be needed for subarachnoid disease.

46 People coinfected with O. volvulus and loiasis should not be treated with diethylcarbamazine (DEC) until the onchocerciasis is treated; their onchocerciasis should not be treated with ivermectin if it is unsafe to treat their loiasis. Patients should only be treated with doxycycline if they no longer live in areas with endemic infection unless there is a contraindication for ivermectin.

47 Doxycycline is not standard therapy, but several studies support its use and safety. Treatment with ivermectin should be given 1 week prior to treatment with doxycycline to provide symptom relief to the patient. If the patient cannot tolerate the dosage of 200 mg, orally, daily of doxycycline, 100 mg, orally, daily is sufficient to sterilize female Onchocerca organisms .

48 For treatment and chronic suppression of toxoplasmosis in human immunodeficiency virus (HIV) infected children, see Guidelines for the Prevention and Treatment of Opportunistic Infections Among HIV-Exposed and HIV-Infected Children, 2013 at http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf .

49 Plus leucovorin, 10–25 mg, with each dose of pyrimethamine.

50 Women who develop toxoplasmosis during the first trimester of pregnancy should be treated with spiramycin (3–4 g/day). After the first trimester, if there is no documented transmission to the fetus, spiramycin can be continued until term. Spiramycin can be obtained at no cost from Aventis through an IND from the FDA (301-796-1600) following confirmation of the diagnosis by a recognized laboratory. If transmission has occurred in utero, therapy with pyrimethamine and sulfadiazine should be started. Pyrimethamine is a potential teratogen and should be used only after the first trimester. Congenitally infected newborns should be treated with pyrimethamine every 2 or 3 days and a sulfonamide daily for approximately 1 year.

Appendix 296.2
Principal Adverse Effects of Antiparasitic Drugs
From The Medical Letter. Principal adverse effects of antiparasitic drugs. Treatment guidelines from The Medical Letter 2013;11(Suppl):e24–e27.

Adverse effects of antiparasitic drugs vary with dosage, duration of administration, concomitant therapy, renal and hepatic function, immune competence, and the age of the patient. The principal adverse effects of antiparasitic agents are listed in the following table. The designation of adverse effects as “frequent,” “occasional,” or “rare” is based on published reports and on the experience of Medical Letter consultants.

Albendazole (Albenza)

  • Frequent: abdominal pain; increased serum transaminases

  • Occasional: reversible alopecia; leukopenia

  • Rare: rash; hepatic toxicity; renal toxicity

Amphotericin B Deoxycholate ( Fungizone , and generics)

  • Frequent: renal damage; hypokalemia; thrombophlebitis at site of peripheral vein infusion; anorexia; headache; nausea; weight loss; bone marrow suppression with reversible decline in hematocrit; chills, fever, vomiting during infusion, possibly with delirium, hypotension or hypertension, wheezing, and hypoxemia, especially in cardiac or pulmonary disease

  • Occasional: hypomagnesemia; normocytic, normochromic anemia

  • Rare: hemorrhagic gastroenteritis; blood dyscrasias; rash; blurred vision; peripheral neuropathy; convulsions; anaphylaxis; arrhythmias; acute liver failure; reversible nephrogenic diabetes insipidus; hearing loss; acute pulmonary edema; spinal cord damage with intrathecal use

Amphotericin B Lipid Formulations (AmBisome, Abelcet, Amphotec)

  • Similar to amphotericin B but generally better tolerated. Nephrotoxicity is less common and less severe with the lipid-based formulations.

  • Acute infusion reactions are worse with Amphotec, less with Abelcet and least with AmBisome. Liver toxicity has been reported.

Artemether (Artenam, Paluther)

  • Occasional: hemolytic anemia (delayed); anorexia; dizziness; nausea; urticaria; rash; reversible neurological changes

Artemether/Lumefantrine (Coartem, Riamet)

  • Frequent: headache; dizziness; anorexia; asthenia; nausea; abdominal pain; vomiting; palpitations; arthralgia; cough

  • Occasional: diarrhea; somnolence; pruritis; rash; vertigo

  • Rare: hypersensitivity; gait disturbance; ataxia; hypoesthesia

Artesunate

  • Occasional: anorexia, dizziness, nausea, diarrhea, ataxia; slurred speech; neurological toxicity

Atovaquone ( Mepron, Malarone [with proguanil])

  • Frequent: rash; nausea

  • Occasional: diarrhea; increased aminotransferases; cholestasis

Azithromycin ( Zithromax , and generics)

  • Occasional: nausea; diarrhea; abdominal pain; headache; dizziness; vaginitis

  • Rare: angioedema; cholestatic jaundice; photosensitivity; reversible dose-related hearing loss; QT prolongation

Benznidazole (Rochagan)

  • Frequent: allergic rash; dose-dependent polyneuropathy; gastrointestinal disturbance

Benzyl ALCOHOL (Ulesfia Lotion)

  • Frequent: eye irritation; contact dermatitis

Bithionol (Bitin)

  • Frequent: photosensitivity reactions; vomiting; diarrhea; abdominal pain; urticaria

  • Rare: leukopenia; toxic hepatitis

Chloroquine HCL and Chloroquine Phosphate ( Aralen , and generics)

  • Occasional: pruritus; vomiting; headache; confusion; depigmentation of hair; skin eruptions; corneal opacity; weight loss; partial alopecia; extraocular muscle palsies; exacerbation of psoriasis, eczema, and other exfoliative dermatoses; myalgias; photophobia

  • Rare: irreversible retinal injury (especially when total dosage exceeds 100 g); discoloration of nails and mucus membranes; nerve-type deafness; peripheral neuropathy and myopathy; heart block; blood dyscrasias; hematemesis

Clarithromycin ( Biaxin , and generics)

  • Occasional: nausea; diarrhea; abdominal pain; abnormal taste; headache; dizziness

  • Rare: reversible dose-related hearing loss; pseudomembranous colitis; pancreatitis; torsades de pointes

Clindamycin ( Cleocin , and generics)

  • Frequent: diarrhea; allergic reactions

  • Occasional: pseudomembranous colitis, sometimes severe, can occur even with topical use

  • Rare: blood dyscrasias; esophageal ulceration; hepatotoxicity; arrhythmia due to QTc prolongation

Crotamiton (Eurax)

  • Occasional: rash

Dapsone

  • Frequent: rash; transient headache; GI irritation; anorexia; infectious mononucleosis-like syndrome

  • Occasional: cyanosis due to methemoglobinemia and sulfhemoglobinemia; other blood dyscrasias, including hemolytic anemia; nephrotic syndrome; liver damage; peripheral neuropathy; hypersensitivity reactions; increased risk of lepra reactions; insomnia; irritability; uncoordinated speech; agitation; acute psychosis

  • Rare: renal papillary necrosis; severe hypoalbuminemia; epidermal necrolysis; optic atrophy; agranulocytosis; neonatal hyperbilirubinemia after use in pregnancy

Diethylcarbamazine Citrate (Hetrazan)

  • Frequent: allergic or febrile reactions, which may be severe, in patients with microfilaria in the blood or the skin; gastrointestinal disturbance

  • Rare: encephalopathy

Diloxanide Furoate (Furamide)

  • Frequent: flatulence

  • Occasional: nausea; vomiting; diarrhea

  • Rare: diplopia; dizziness; urticaria; pruritus

Eflornithine (Difluoromethylornithine, DFMO, Ornidyl )

  • Frequent: anemia; leukopenia

  • Occasional: diarrhea; thrombocytopenia; seizures

  • Rare: hearing loss

Fluconazole ( Diflucan , and generics)

  • Occasional: nausea; vomiting; diarrhea; abdominal pain; headache; rash; increased aminotransferases

  • Rare: severe hepatic toxicity; exfoliative dermatitis; anaphylaxis; Stevens-Johnson syndrome; toxic epidermal necrolysis; hair loss

Flucytosine (Ancobon)

  • Frequent: blood dyscrasias, including pancytopenia and fatal agranulocytosis; gastrointestinal disturbance, including severe diarrhea and ulcerative colitis; rash; hepatic dysfunction

  • Occasional: confusion; hallucinations

  • Rare: anaphylaxis

Furazolidone (Furoxone)

  • Frequent: nausea; vomiting

  • Occasional: allergic reactions, including pulmonary infiltration; hypotension; urticaria; fever; vesicular rash; hypoglycemia; headache

  • Rare: hemolytic anemia in G6PD deficiency and neonates; disulfiram-like reaction with alcohol; MAO-inhibitor interactions; polyneuritis

Iodoquinol ( Yodoxin , and generics)

  • Occasional: rash; acne; slight enlargement of the thyroid gland; nausea; diarrhea; cramps; anal pruritus

  • Rare: optic neuritis, atrophy and loss of vision; peripheral neuropathy after prolonged use in high dosage (for months); iodine sensitivity

Itraconazole ( Sporanox , and generics)

  • Occasional: nausea; epigastric pain; headache; dizziness; edema; hypokalemia; rash; hepatic toxicity

  • Rare: congestive heart failure

  • IVERMECTIN—oral (Stromectol)

  • Occasional: Mazzotti-type reaction seen in onchocerciasis, including fever; pruritus; tender lymph nodes; headache; and joint and bone pain

  • Rare: hypotension

Ivermectin—lotion (Sklice)

  • Occasional: conjunctivitis; ocular hyperemia; eye irritation; dandruff; burning sensation of the skin

Ketoconazole ( Nizoral , and generics)

  • Frequent: nausea; vomiting

  • Occasional: decreased testosterone synthesis; gynecomastia; oligospermia and impotence in men; abdominal pain; rash; hepatitis; pruritus; dizziness; constipation; diarrhea; fever and chills; photophobia; headache

  • Rare: fatal hepatic necrosis; liver injury with jaundice; transient elevated transaminase; severe epigastric burning and pain; may interfere with adrenal function; anaphylaxis

Malathion (Ovide)

  • Occasional: local irritation

Mebendazole (Vermox)

  • Occasional: diarrhea; abdominal pain

  • Rare: leukopenia; agranulocytosis; hypospermia

Mefloquine (Lariam)

  • Frequent: vertigo; lightheadedness; nausea; other gastrointestinal disturbances; nightmares; visual disturbances; headache; insomnia

  • Occasional: confusion

  • Rare: psychosis; hypotension; convulsions; coma; paresthesias

Meglumine Antimoniate (Glucantime)

  • Similar to sodium stibogluconate

Melarsoprol (Mel B)

  • Frequent: myocardial damage; albuminuria; hypertension; colic; Herxheimer-type reaction; encephalopathy; vomiting; peripheral neuropathy

  • Rare: shock

Metronidazole ( Flagyl , and generics)

  • Frequent: nausea; headache; anorexia; metallic taste

  • Occasional: vomiting; diarrhea; insomnia; weakness; dry mouth; stomatitis; vertigo; tinnitus; paresthesias; rash; dark urine; urethral burning; disulfiram-like reaction with alcohol; candidiasis

  • Rare: pseudomembranous colitis; leukopenia; pancreatitis; seizures; peripheral neuropathy; encephalopathy; cerebellar syndrome with ataxia, dysarthria and MRI abnormalities

Miconazole (Monistat)

  • Occasional: phlebitis; thrombocytosis; chills; intense, persistent pruritus; rash; vomiting; hyperlipidemia; dizziness; blurred vision; local burning and irritation with topical use

  • Rare: anemia; thrombocytopenia; hyponatremia; renal insufficiency; anaphylaxis; cardiac and respiratory arrest with initial dose

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