Principles of Antiparasitic Therapy

Parasites are divided into three main groups taxonomically: protozoans, which are unicellular, and helminths and ectoparasites, which are multicellular. Chemotherapeutic agents appropriate for one group may not be appropriate for the others, and not all drugs are readily available ( Table 305.1 ). Some drugs are not available in the United States, and some are available only from the manufacturer, specialized compounding pharmacies, or the Centers for Disease Control and Prevention (CDC). Information on the availability of drugs and expert guidance in management can be obtained by contacting the CDC Parasitic Diseases Branch (1-404-718-4745; e-mail parasites@cdc.gov (M-F, 8 am -4 pm , Eastern time). For assistance in the management of malaria, healthcare providers should call the CDC Malaria Hotline: 1-770-488-7788 or 1-855-856-4713 toll-free (M-F, 9 am -5 pm , Eastern time). For all emergency consultations after hours, clinicians can contact the CDC Emergency Operations Center at 1-770-488-7100 and request to speak with a CDC Malaria Branch clinician or on-call parasitic diseases physician. Some antiparasitic drugs are not licensed for use in the United States but can be obtained as investigational new drugs (INDs) from the CDC; providers should call the CDC Drug Service, Division of Scientific Resources and Division of Global Migration and Quarantine, at 1-404-639-3670.

Table 305.1

Drugs for Parasitic Infections

From Drugs for parasitic infection, Med Lett 11(Suppl):e1-e23, 2013. Available at http://www.medicalletter.org .

Parasitic infections are found throughout the world. With increasing travel, immigration, use of immunosuppressive drugs, and the spread of HIV, physicians anywhere may see infections caused by previously unfamiliar parasites. The table below lists first-choice and alternative drugs for most parasitic infections.
INFECTION	DRUG	ADULT DOSAGE	PEDIATRIC DOSAGE
Acanthamoeba keratitis
Drug of choice:	See footnote 1
Amebiasis (Entamoeba histolytica)
Asymptomatic infection
Drug of choice:	Iodoquinol (Yodoxin) ²	650 mg PO tid × 20 days	30-40 mg/kg/day (max 1950 mg) in 3 doses PO × 20 days
or	Paromomycin	25-35 mg/kg/day PO in 3 doses × 7 days	25-35 mg/kg/day PO in 3 doses × 7 days
Alternative:	Diloxanide furoate ³	500 mg tid PO × 10 days	20 mg/kg/day PO in 3 doses × 10 days
Mild to moderate intestinal disease
Drug of choice:	Metronidazole	500-750 mg tid PO × 7-10 days	35-50 mg/kg/day PO in 3 doses × 7-10 days
or	Tinidazole ⁴	2 g PO once daily × 3 days	50 mg/kg/day PO (max 2 g) in 1 dose × 3 days
Either followed by:	Iodoquinol ²	650 mg PO tid × 20 days	30-40 mg/kg/day PO in 3 doses × 20 days (max 2 g)
or	Paromomycin	25-35 mg/kg/day PO in 3 doses × 7 days	25-35 mg/kg/day PO in 3 doses × 7 days
Alternative:	Nitazoxanide ⁵	500 mg bid × 3 days	1-3 yr: 100 mg bid × 3 days
			4-11 yr: 100 mg bid × 3 days
			12+ yr: use adult dosing
Severe intestinal and extraintestinal disease
Drug of choice:	Metronidazole	750 mg PO tid × 7-10 days	35-50 mg/kg/day PO in 3 doses × 7-10 days
or	Tinidazole ⁴	2 g PO once daily × 5 days	50 mg/kg/day PO (max 2 g) × 5 days
Either followed by:	Iodoquinol ²	650 mg PO tid × 20 days	30-40 mg/kg/day PO in 3 doses × 20 days (max 2 g)
or	Paromomycin	25-35 mg/kg/day PO in 3 doses × 7 days	25-35 mg/kg/day PO in 3 doses × 7 days
Amebic meningoencephalitis, primary and granulomatous
*Naegleria fowleri*
Drug of choice:	Amphotericin B deoxycholate ^6,7	1.5 mg/kg/day IV in 2 divided doses × 3 days, then 1 mg/kg daily IV × 11 days	1.5 mg/kg/day IV in 2 divided doses × 3 days, then 1 mg/kg daily IV × 11 days
	plus Amphotericin B deoxycholate ^6,7	1.5 mg/kg intrathecally daily × 2 days, then 1 mg/kg intrathecally every other day × 8 days	1.5 mg/kg intrathecally daily × 2 days, then 1 mg/kg intrathecally every other day × 8 days
	plus Rifampin ⁷	10 mg/kg (max 600 mg) IV or PO daily × 28 days	10 mg/kg (max 600 mg) IV or PO daily × 28 days
	plus Fluconazole ⁷	10 mg/kg (max 600 mg) IV or PO daily × 28 days	10 mg/kg (max 600 mg) IV or PO daily × 28 days
	plus Azithromycin ⁷	500 mg IV or PO daily × 28 days	10 mg/kg (max 500 mg) IV or PO daily × 28 days
	plus Miltefosine ^6,7,8	50 mg PO tid × 28 days	<45 kg: 50 mg bid (max 2.5 mg/kg) × 28 days
	plus Miltefosine ^6,7,8	50 mg PO tid × 28 days	≥45 kg: use adult dosing
	plus Dexamethasone	0.6 mg/kg/day IV in 4 divided doses × 4 days	0.6 mg/kg/day IV in 4 divided doses × 4 days
*Acanthamoeba*
Drug of choice:	See footnotes 7, 8
*Balamuthia mandrillaris*
Drug of choice:	See footnotes 7, 9a, 9b
*Sappinia diploidea*
Drug of choice:	See footnote 10
Ancylostoma caninum (eosinophilic enterocolitis)
Drug of choice:	Albendazole ⁷	400 mg PO once	<10 kg/2 yr: ¹¹
Drug of choice:	Albendazole ⁷	400 mg PO once	≥2 yr: see adult dosing
or	Mebendazole	100 mg PO bid × 3 days	100 mg PO bid × 3 days ¹²
or	Pyrantel pamoate (OTC) ⁷	11 mg/kg PO (max 1 g) × 3 days	11 mg/kg PO (max 1 g) × 3 days
or	Endoscopic removal
Ancylostoma duodenale, see Hookworm
Angiostrongyliasis (Angiostrongylus cantonensis, Angiostrongylus costaricensis)
Drug of choice:	See footnote 13
*Anisakiasis ( Anisakis* spp.)**
Treatment of choice:	Surgical or endoscopic removal
Alternative:	Albendazole ^7,14	400 mg PO bid × 6-21 days	<10 kg/2 yr: ¹¹
Alternative:	Albendazole ^7,14	400 mg PO bid × 6-21 days	≥2 yr: see adult dosing
*Ascariasis ( Ascaris lumbricoides,* roundworm)**
Drug of choice:	Albendazole ⁷	400 mg PO once	<10 kg/2 yr: see adult dosing ¹¹
Drug of choice:	Albendazole ⁷	400 mg PO once	≥2 yr: see adult dosing
or	Mebendazole	100 mg PO bid × 3 days or 500 mg PO once	100 mg PO bid × 3 days or 500 mg PO once ¹²
or	Ivermectin ⁷	150-200 µg/kg PO once	<15 kg: not indicated
or	Ivermectin ⁷	150-200 µg/kg PO once	≥15 kg: see adult dosing
Babesiosis (Babesia microti)
Drugs of choice: ¹⁵	Atovaquone ⁷	750 mg PO bid × 7-10 days	20 mg/kg (max 750 mg) PO bid × 7-10 days
Drugs of choice: ¹⁵	plus Azithromycin ⁷	500-1000 mg once, then 250 mg daily × 7-10 days. Higher doses (600-1000 mg) and/or prolonged therapy (6 wk or longer) may be required for immunocompromised patients.	10 mg/kg PO on day 1 (max 500 mg/dose), then 5 mg/kg/day (max 250 mg/dose) PO on days 2-10
or	Clindamycin ⁷	300-600 mg IV qid or 600 mg tid PO × 7-10 days	20-40 mg/kg/day IV or PO in 3 or 4 doses × 7-10 days (max 600 mg/dose)
or	plus Quinine ⁷	648 mg tid PO × 7-10 days	10 mg/kg (max 648 mg) PO tid × 7-10 days
Balamuthia mandrillaris, see Amebic meningoencephalitis, primary
Balantidiasis (Balantidium coli)
Drug of choice:	Tetracycline ^7,16	500 mg PO qid × 10 days	<8 yr: not indicated
Drug of choice:	Tetracycline ^7,16	500 mg PO qid × 10 days	≥8 yr: 10 mg/kg (max 500 mg) PO qid × 10 days
Alternative:	Metronidazole ⁷	750 mg PO tid × 5 days	35-50 mg/kg/day PO in 3 divided doses × 5 days
or	Iodoquinol ^2,7	650 mg PO tid × 20 days	30-40 mg/kg/day (max 2 g) PO in 3 divided doses × 20 days
or	Nitazoxanide ^4,7	500 mg PO bid × 3 days	1-3 yr: 100 mg PO bid × 3 days
			4-11 yr: 200 mg PO bid × 3 days
			12+ yr: see adult dosing
Baylisascariasis (Baylisascaris procyonis)
Drug of choice:	Albendazole ^7,17	400 mg PO BID × 10-20 days	<10 kg/2 yr: 25-50 mg/kg/day PO in 1-2 divided doses × 10-20 days ¹¹
Drug of choice:	Albendazole ^7,17	400 mg PO BID × 10-20 days	≥2 yr: 25-50 mg/kg/day PO in 1-2 divided doses × 10-20 days
Blastocystis hominis infection
Drug of choice:	See footnote 18
Capillariasis (Capillaria philippinensis)
Drug of choice:	Mebendazole ⁷	200 mg PO bid × 20 days	200 mg PO bid × 20 days ¹²
Alternative:	Albendazole ⁷	400 mg PO daily × 10 days	<10 kg/2 yr: ¹¹
Alternative:	Albendazole ⁷	400 mg PO daily × 10 days	≥2 yr: see adult dosing
Chagas disease, see Trypanosomiasis
Clonorchis sinensis, see Fluke infection
Cryptosporidiosis (Cryptosporidium parvum)
Immunocompetent
Drug of choice:	Nitazoxanide ⁴	500 mg PO bid × 3 days	1-3 yr: 100 mg PO bid × 3 days
			4-11 yr: 200 mg PO bid × 3 days
			12+ yr: see adult dosing
HIV infected
Drug of choice:	See footnote 19
*Cutaneous larva migrans ( Ancylostoma braziliense, A. caninum,* dog and cat hookworm, creeping eruption)**
Drug of choice:	Albendazole ^7,20	400 mg PO daily × 3-7 days	<10 kg/2 yr: 200 mg PO daily × 3 days ¹¹
Drug of choice:	Albendazole ^7,20	400 mg PO daily × 3-7 days	≥2 yr: see adult dosing
or	Ivermectin ⁷	200 µg/kg PO daily × 1-2 days	<15 kg: not indicated
or	Ivermectin ⁷	200 µg/kg PO daily × 1-2 days	≥15 kg: see adult dosing
Alternative:	Thiabendazole	Apply topically tid × 7 days	Apply topically tid × 7 days
Cyclosporiasis (Cyclospora cayetanensis)
Drug of choice:	Trimethoprim-sulfamethoxazole (TMP-SMX) ^7,21	TMP 160 mg/SMX 800 mg (1 DS tab) PO bid × 7-10 days	4-5 mg/kg TMP component (max 160 mg) PO bid × 7-10 days
Cysticercosis, see Tapeworm infection
Cystoisosporiasis (Cystoisospora belli, formerly known as Isospora)
Drug of choice:	Trimethoprim-sulfamethoxazole (TMP-SMX) ⁷	TMP 160 mg/SMX 800 mg (1 DS tablet) PO bid × 10 days	4-5 mg/kg TMP component (max 160 mg) PO bid × 10 days
Alternative:	Pyrimethamine	50-75 mg PO divided bid × 10 days	—
Alternative:	plus Leukovorin	10-25 mg PO daily × 10 days	—
or	Ciprofloxacin ⁷	500 mg PO bid × 7-10 days	—
Dientamoeba fragilis infection ²²
	Paromomycin ⁷	25-35 mg/kg/day PO in 3 doses × 7 days	25-35 mg/kg/day PO in 3 divided doses × 7 days
or	Iodoquinol ²	650 mg PO tid × 20 days	30-40 mg/kg/day PO (max 2 g) in 3 divided doses × 20 days
or	Metronidazole ⁷	500-750 mg tid × 10 days	35-50 mg/kg/day in 3 divided doses × 10 days
Diphyllobothrium latum, see Tapeworm infection
Dracunculus medinensis (guinea worm) infection
Treatment of choice:	Slow mechanical extraction of worm ²³
Echinococcus, see Tapeworm infection
Entamoeba histolytica, see Amebiasis
Enterobius vermicularis (pinworm) infection ²⁴
Drug of choice:	Albendazole ⁷	400 mg PO once; repeat in 2 wk	<10 kg/2 yr: 200 mg PO once; repeat in 2 wk ¹¹
Drug of choice:	Albendazole ⁷	400 mg PO once; repeat in 2 wk	≥2 yr: see adult dosing
or	Mebendazole	100 mg PO once; repeat in 3 wk	100 mg PO once; repeat in 3 wk ¹²
or	Pyrantel pamoate (OTC)	11 mg/kg base PO once (max 1 g); repeat in 2 wk	11 mg/kg base PO once (max 1 g); repeat in 2 wk
Fasciola hepatica, see Fluke infection
Filariasis ²⁵
Lymphatic filariasis (Wuchereria bancrofti, Brugia malayi, Brugia timori)
Drug of choice: ²⁶	Diethylcarbamazine ^27,28	6 mg/kg once or 6 mg/kg PO in 3 divided doses × 12 days ²⁹	<18 mo: no indication
Drug of choice: ²⁶	Diethylcarbamazine ^27,28	6 mg/kg once or 6 mg/kg PO in 3 divided doses × 12 days ²⁹	≥18 mo: see adult dosing
*Loa loa*
<8,000 microfilaria/mL ²⁸
Drug of choice:	Diethylcarbamazine ^27,28	9 mg/kg PO in 3 doses × 14 days ²⁹	<18 mo: no indication
Drug of choice:	Diethylcarbamazine ^27,28	9 mg/kg PO in 3 doses × 14 days ²⁹	≥18 mo: see adult dosing
Alternative:	Albendazole ²⁷	200 mg PO bid × 21 days	<10 kg/2 yr: ¹¹
Alternative:	Albendazole ²⁷	200 mg PO bid × 21 days	≥2 yr: see adult dosing
≥8,000 microfilaria/mL ^28,30
Treatment of choice:	Apheresis
or	Albendazole ²⁷	200 mg PO bid × 21 days	<10 kg/2 yr: ¹¹
or	Albendazole ²⁷	200 mg PO bid × 21 days	≥2 yr: see adult dosing
Either followed by:	Diethylcarbamazine ^27,28	8-10 mg/kg PO in 3 doses × 21 days ²⁹	<18 mo: no indication
Either followed by:	Diethylcarbamazine ^27,28	8-10 mg/kg PO in 3 doses × 21 days ²⁹	≥18 mo: see adult dosing
*Mansonella ozzardi*
Drug of choice:	See footnote 31
*Mansonella perstans*
Drug of choice:	Doxycycline ^7,16,32	100 mg bid PO × 6 wk	4 mg/kg/day in 2 doses PO × 6 wk
*Mansonella streptocerca* ³³
Drug of choice:	Diethylcarbamazine	6 mg/kg/day PO × 14 days	6 mg/kg/day PO × 14 days
or	Ivermectin ⁷	150 µg/kg PO once	<15 kg: not indicated
or	Ivermectin ⁷	150 µg/kg PO once	≥15 kg: see adult dosing
Tropical pulmonary eosinophilia (TPE) ³⁴
Drug of choice:	Diethylcarbamazine ²⁷	6 mg/kg once or 6 mg/kg PO in 3 divided doses × 14-21 days ²⁶	<18 mo: no indication
Drug of choice:	Diethylcarbamazine ²⁷		≥18 mo: see adult dosing
Onchocerca volvulus (river blindness)
Drug of choice:	Ivermectin ³⁵	150 µg/kg PO once, repeated every 6-12 mo until asymptomatic	<15 kg: not indicated
Drug of choice:	Ivermectin ³⁵		≥15 kg: see adult dosing
Fluke, hermaphroditic, infection
Clonorchis sinensis (Chinese liver fluke)
Drug of choice:	Praziquantel	25 mg/kg PO tid × 2 days	25 mg/kg PO tid × 2 days ³⁶
or	Albendazole ⁷	10 mg/kg PO × 7 days	<10 kg/2 yr: ¹¹
or	Albendazole ⁷	10 mg/kg PO × 7 days	≥2 yr: see adult dosing
Fasciola hepatica (sheep liver fluke)
Drug of choice:	Triclabendazole ^7,37,38	10 mg/kg PO once or twice	10 mg/kg PO once or twice
Alternative:	Nitazoxanide ⁷	500 mg PO bid × 7 days	1-3 yr: 100 mg PO bid
			4-11 yr: 200 mg PO bid
			≥12 yr: see adult dosing
or	Bithionol ^3,7	30-50 mg/kg PO on alternate days × 10-15 doses	30-50 mg/kg PO on alternate days × 10-15 doses
Fasciolopsis buski, Heterophyes heterophyes, Metagonimus yokogawai (intestinal flukes)
Drug of choice:	Praziquantel ⁷	25 mg/kg PO tid × 1 day	25 mg/kg PO tid × 1 day ³⁶
Metorchis conjunctus (North American liver fluke) ³⁹
Drug of choice:	Praziquantel ⁷	25 mg/kg PO tid × 1 day	25 mg/kg PO tid × 1 day ³⁶
*Nanophyetus salmincola*
Drug of choice:	Praziquantel ⁷	20 mg/kg PO tid × 1 day	20 mg/kg PO tid × 1 day ³⁶
Opisthorchis viverrini (Southeast Asian liver fluke), O. felineus (cat liver fluke)
Drug of choice:	Praziquantel	25 mg/kg PO tid × 2 days	25 mg/kg PO tid × 2 days ³⁶
or	Albendazole ⁷	10 mg/kg PO × 7 days	<10 kg/2 yr: ¹¹
or	Albendazole ⁷	10 mg/kg PO × 7 days	≥2 yr: see adult dosing
Paragonimus westermani (lung fluke)
Drug of choice:	Praziquantel ⁷	25 mg/kg PO tid × 2 days	25 mg/kg PO tid × 2 days ³⁶
or	Triclabendazole ^7,40	10 mg/kg PO bid × 1 day or 5 mg/kg daily × 3 days	10 mg/kg PO bid × 1 day or 5 mg/kg daily × 3 days
or	Bithionol ^3,7	30-50 mg/kg PO on alternate days × 10-15 doses	30-50 mg/kg PO on alternate days × 10-15 doses
Giardiasis (Giardia intestinalis, also known as G. duodenalis or G. lamblia)
Drug of choice:	Metronidazole ⁷	250 mg PO tid × 5 days	5 mg/kg (max 250 mg) PO tid × 5 days
or	Nitazoxanide ⁵	500 mg PO bid × 3 days	1-3 yr: 100 mg PO every 12 hr × 3 days
			4-11 yr: 200 mg PO every 12 hr × 3 days
			12+ yr: see adult dosing
or	Tinidazole ⁴	2 g PO once	50 mg/kg PO once (max 2 g)
Alternative: ⁴¹	Paromomycin ^7,42	25-35 mg/kg/day PO in 3 doses × 7 days	25-35 mg/kg/day PO in 3 doses × 7 days
or	Furazolidone ³	100 mg PO qid × 7-10 days	6 mg/kg/day PO in 4 doses × 7-10 days
or	Quinacrine ²	100 mg PO tid × 5 days	2 mg/kg tid PO × 5 days (max 300 mg/day)
Gnathostomiasis (Gnathostoma spinigerum)
Treatment of choice: ⁴³	Albendazole ⁷	400 mg PO bid × 21 days	<10 kg/2 yr: ¹¹
Treatment of choice: ⁴³	Albendazole ⁷	400 mg PO bid × 21 days	≥2 yr: see adult dosing
or	Ivermectin ⁷	200 µg/kg/day PO × 2 days	<15 kg: not indicated
or	Ivermectin ⁷	200 µg/kg/day PO × 2 days	≥15 kg: see adult dosing
±	Surgical removal
*Gongylonemiasis ( Gongylonema* sp.)** ⁴⁴
Treatment of choice:	Surgical removal
or	Albendazole ⁷	400 mg PO daily × 3 days	10 mg/kg/day PO × 3 days
Hookworm infection (Ancylostoma duodenale, Necator americanus)
Drug of choice:	Albendazole ⁷	400 mg PO once	<10 kg/2 yr: ¹¹
Drug of choice:	Albendazole ⁷	400 mg PO once	≥2 yr: see adult dosing
or	Mebendazole	100 mg PO bid × 3 days or 500 mg once	100 mg PO bid × 3 days or 500 mg once ¹²
or	Pyrantel pamoate (OTC) ⁷	11 mg/kg (max 1 g) PO × 3 days	11 mg/kg (max 1 g) PO × 3 days
Hydatid cyst, see Tapeworm infection
Hymenolepis nana, see Tapeworm infection
Leishmania infection ⁴⁵
Visceral ⁴⁶
Drug of choice:	Liposomal amphotericin B (AmBisome) ^47,48	3 mg/kg/day IV on days 1-5, 14, and 21 (total dose 21 mg/kg)	3 mg/kg/day IV on days 1-5, 14, and 21 (total dose 21 mg/kg)
or	Miltefosine ⁴⁹	30-44 kg: 50 mg PO bid × 28 days	<12 yr: 2.5 mg/kg daily × 28 days ⁷
or	Miltefosine ⁴⁹	≥45 kg: 50 mg PO tid × 28 days	12 yr: see adult dosing
or	Sodium stibogluconate (Pentostam) ^27,50	20 mg/kg/day IV or IM × 28 days	20 mg/kg/day IV or IM × 28 days
or	Amphotericin B deoxycholate ⁷	1 mg/kg IV daily or every 2 days for 15-20 doses	1 mg/kg IV daily or every 2 days for 15-20 doses
Alternative:	Meglumine antimoniate ^3,50	20 mg pentavalent antimony/kg/day IV or IM × 28 days	20 mg pentavalent antimony/kg/day IV or IM × 28 days
or	Pentamidine ⁷	4 mg/kg IV or IM daily or every 2 days for 15-30 doses	4 mg/kg IV or IM daily or every 2 days for 15-30 doses
Cutaneous ^51,52
Drug of choice:	Sodium stibogluconate ^27,50	20 mg/kg/day IV or IM × 20 days	20 mg/kg/day IV or IM × 20 days
or	Liposomal amphotericin B (AmBisome) ⁷	3 mg/kg/day IV on days 1-5 and 10 or 1-7 (total dose 18-21 mg/kg)	3 mg/kg/day IV on days 1-5 and 10 or 1-7 (total dose 18-21 mg/kg)
or	Amphotericin B deoxycholate ⁷	0.5-1 mg/kg IV daily or every 2 days (total dose 15-30 mg/kg)	0.5-1 mg/kg IV daily or every 2 days (total dose 15-30 mg/kg)
or	Miltefosine ⁴⁹	30-44 kg: 50 mg PO bid × 28 days	<12 yr: 2.5 mg/kg daily × 28 days ⁷
or	Miltefosine ⁴⁹	≥45 kg: 50 mg PO tid × 28 days	12 yr: see adult dosing
Alternatives:	Meglumine antimoniate ^3,50	20 mg pentavalent antimony/kg/day IV or IM × 20 days	20 mg pentavalent antimony/kg/day IV or IM × 20 days
or	Pentamidine ^7,53	3-4 mg/kg IV or IM every 2 days × 3-4 doses	2-3 mg/kg IV or IM daily or every 2 days × 4-7 doses
or	Paromomycin ^7,54	Topically 2×/day × 10-20 days	Topically 2×/day × 10-20 days
or	Ketoconazole ⁷	600 mg daily × 28 days
or	Fluconazole ⁷	200 mg daily × 6 wk
or	Local therapy, including cryotherapy, thermotherapy, intralesional Sb ^V , topical paromomycin, photodynamic or laser therapy
Mucosal ^54, ⁵⁵
Drug of choice:	Sodium stibogluconate ^27,50	20 mg/kg/day IV or IM × 28 days	20 mg/kg/day IV or IM × 28 days
or	Liposomal amphotericin B (AmBisome) ⁷	3 mg/kg/day IV × 10 days or 4 mg/kg on days 1-5, 10, 17, 24, 31, and 38 (total dose 20-60 mg/kg)	2-4 mg/kg/day IV × 10 days or 4 mg/kg on days 1-5, 10, 17, 24, 31, and 38 (total dose 20-60 mg/kg)
or	Amphotericin B deoxycholate ⁷	0.5-1 mg/kg IV daily or every 2 days (total dose 20-45 mg/kg)	0.5-1 mg/kg IV daily or every 2 days (total dose 20-45 mg/kg)
or	Miltefosine ⁴⁹	30-44 kg: 50 mg PO bid × 28 days	<12 yr: 2.5 mg/kg daily × 28 days ⁷
or	Miltefosine ⁴⁹	≥45 kg: 50 mg PO tid × 28 days	12 yr: see adult dosing
Alternative:	Meglumine antimoniate ^3,50	20 mg pentavalent antimony/kg/day IV or IM × 28 days	20 mg pentavalent antimony/kg/day IV or IM × 28 days
Lice (head and body) infestation (Pediculus humanus capitis, Pediculus humanus humanus)
Drug of choice:	0.5% Malathion (Ovide) ⁵⁶	Topically 2x, 1 wk apart	Topically 2x, 1 wk apart, approved for ≥ 6 yr
or	1% Permethrin (Nix) (OTC) ⁵⁶	Topically 2x, 1 wk apart	Topically 2x, 1 wk apart, approved for ≥ 2 mo
or	Pyrethrins with piperonyl butoxide (A-200, Pronto, R&C, Rid, Triple X) (OTC) ⁵⁷	Topically 2x, 1 wk apart	Topically 2x, 1 wk, approved for ≥ 2 yr
or	0.5% Ivermectin lotion (Sklice)	Topically, once	Topically once, approved for ≥ 6 mo
or	0.9% Spinosad suspension (Natroba)	Topically once, 2nd dose in 1 wk if live adult lice seen	Topically once, 2nd dose in 1 wk if live adult lice seen, approved for ≥ 6 mo
or	Ivermectin ^7,58	200-400 µg/kg PO 2x, 1 wk apart	<15 kg: not indicated
or	Ivermectin ^7,58	200-400 µg/kg PO 2x, 1 wk apart	≥15 kg: see adult dosing
or	5% Benzyl alcohol lotion (Ulesfia)	Topically 2x, 1 wk apart	Topically 2x, 1 wk apart
Lice (pubic) infestation (Phthirus pubis) ⁵⁹
Drug of choice:	1% Permethrin (Nix) (OTC) ⁵⁶	Topically 2x, 1 wk apart	Topically 2x, 1 wk apart, approved for ≥ 2 mo
or	Pyrethrins with piperonyl butoxide (A-200, Pronto, R&C, Rid, Triple X) (OTC) ⁵²	Topically 2x, 1 wk apart	Topically 2x, 1 wk apart, approved for ≥ 2 yr
or	0.5% Malathion (Ovide) ⁵⁶	Topically 2x, 1 wk apart	Topically 2x, 1 wk apart, approved for ≥ 6 yr
or	0.5% Ivermectin lotion (Sklice)	Topically, once	Topically once, approved for ≥ 6 mo
or	Ivermectin ^7,58	200-400 µg/kg PO 2x, 1 wk apart	<15 kg: not indicated
or	Ivermectin ^7,58	200-400 µg/kg PO 2x, 1 wk apart	≥15 kg: see adult dosing
Loa loa, see Filariasis
*Malaria (Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax,* and Plasmodium malariae) Treatment**
*Uncomplicated infection due to P. falciparum* or species not identified acquired in areas of chloroquine resistance or unknown resistance** ⁶⁰
Drug of choice: ⁶¹	Atovaquone/proguanil (Malarone) Adult tablets: 50 mg atovaquone/100 mg proguanil Pediatric tablets: 62.5 mg atovaquone/25 mg proguanil ⁶²	4 adult tablets PO once daily or 2 adult tablets PO bid × 3 days ⁶³	<5 kg: not indicated
			5-8 kg: 2 pediatric tablets PO daily × 3 days
			9-10 kg: 3 pediatric tablets PO daily × 3 days
			11-20 kg: 1 adult tablet PO daily × 3 days
			21-30 kg: 2 adult tablets PO daily × 3 days
			31-40 kg: 3 adult tablets PO daily × 3 days
			>40 kg: 4 adult tablets PO daily × 3 days
or	Coartem (artemether-lumefantrine) Fixed dose of 20 mg artemether and 120 mg lumefantrine per tablet	4 tablets per dose. A 3- day treatment schedule with a total of 6 oral doses is recommended for both adult and pediatric patients based on weight. These 6 doses should be administered over 3 days at 0, 8, 24, 36, 48, and 60 h5.	5 to < 15 kg: 1 tablet PO per dose
			15 to < 25 kg: 2 tablets PO per dose
			25 to < 35 kg: 3 tablets per dose
			≥35 kg: 4 tablets PO per dose
or	Quinine sulfate	648 mg salt PO tid × 3-7 days ⁶³	10 mg salt/kg PO tid × 3-7 days ⁶⁴
	plus Doxycycline ^7,16	100 mg PO bid × 7 days	4 mg/kg/day PO in 2 doses × 7 days
	or plus Tetracycline ^7,16	250 mg PO qid × 7 days	6.25 mg/kg PO qid × 7 days
	or plus Clindamycin ^7,65	20 mg/kg/day PO in 3 divided doses × 7 days ⁶⁶	20 mg/kg/day PO in 3 doses × 7 days
Alternative:	Mefloquine ^67,68	750 mg PO followed 12 hr later by 500 mg	15 mg/kg PO followed 12 hr later by 10 mg/kg
Uncomplicated infection due to P. falciparum or species not identified acquired in areas of chloroquine sensitivity or uncomplicated P. malariae or P. knowlesi
Drug of choice:	Chloroquine phosphate (Aralen)	600 mg base PO, then 300 mg base PO at 6, 24, and 48 hr	10 mg/kg base PO, then 5 mg/kg base PO at 6, 24, and 48 hr
or	Hydroxychloroquine (Plaquenil) ⁷¹	620 mg base PO, then 310 mg base PO at 6, 24, and 48 hr	10 mg/kg base PO, then 5 mg/kg base PO at 6, 24, and 48 hr
*Uncomplicated infection with P. vivax* acquired in areas of chloroquine resistance** ⁶⁸
Drug of choice:	Atovaquone/proguanil (Malarone) Adult tablets: 50 mg atovaquone/100 mg proguanil Pediatric tablets: 62.5 mg atovaquone/25 mg proguanil ⁶²	4 adult tablets PO once daily × 3 days	<5 kg: not indicated
			5-8 kg: 2 pediatric tablets PO daily × 3 days
			9-10 kg: 3 pediatric tablets PO daily × 3 days
			11-20 kg: 1 adult tablet PO daily × 3 days
			21-30 kg: 2 adult tablets PO daily × 3 days
			31-40 kg: 3 adult tablets PO daily × 3 days
			>40 kg: 4 adult tablets PO daily × 3 days
	plus Primaquine ⁷⁰	30 mg base PO daily × 14 days	0.5 mg/kg/day PO × 14 days
or	Quinine sulfate	648 mg salt PO tid × 3-7 days ⁶³	10 mg salt/kg PO tid × 3-7 days ⁵⁷
	plus Doxycycline ^7,16	100 mg PO bid × 7 days	4 mg/kg/day PO in 2 doses × 7 days
	or plus Tetracycline ^7,16	250 mg PO qid × 7 days	6.25 mg/kg PO qid × 7 days
	or plus Clindamycin ^7,65	20 mg/kg/day PO in 3 divided doses × 7 days ⁶⁶	20 mg/kg/day PO in 3 doses × 7 days
	plus Primaquine ⁶⁹	30 mg base PO daily × 14 days	0.5 mg/kg/day PO × 14 days
or	Mefloquine ⁶⁷	750 mg PO followed 12 hr later by 500 mg PO	15 mg/kg PO followed 12 hr later by 10 mg/kg PO
or	plus Primaquine ⁷⁰	30 mg base PO daily × 14 days	0.5 mg/kg/day PO × 14 days
*Uncomplicated infection with P. ovale* and P. vivax acquired in areas without chloroquine resistance** ⁶⁸
Drug of choice:	Chloroquine phosphate (Aralen)	600 mg base PO, then 300 mg base PO at 6, 24, and 48 hr	10 mg/kg base PO, then 5 mg/kg base PO at 6, 24, and 48 hr
Drug of choice:	plus Primaquine ⁷⁰	30 mg base PO daily × 14 days	0.5 mg/kg/day PO × 14 days
or	Hydroxychloroquine (Plaquenil) ⁷¹	620 mg base PO, then 310 mg base PO at 6, 24, and 48 hr	10 mg/kg base PO, then 5 mg/kg base PO at 6, 24, and 48 hr
or	plus Primaquine ⁷⁰	30 mg base PO daily × 14 days	0.5 mg/kg/day PO × 14 days
*Severe malaria due to all Plasmodium* spp.**
Drug of choice: ⁷²	Quinidine gluconate ⁷³	10 mg salt/kg IV in normal saline loading dose (max 600 mg) over 1-2 hr, followed by continuous infusion of 0.02 mg salt/kg/min until PO therapy can be started	10 mg salt/kg IV in normal saline loading dose (max 600 mg) over 1-2 hr, followed by continuous infusion of 0.02 mg salt/kg/min until PO therapy can be started
	plus Doxycycline ^7,16	100 mg PO or IV bid × 7 days	4 mg/kg/day PO or IV in 2 doses × 7 days
	or plus Tetracycline ^7,16	250 mg PO qid × 7 days	6.25 mg/kg PO qid × 7 days
	or plus Clindamycin ^7,65	20 mg/kg/day PO in 3 divided doses × 7 days or 10 mg/kg IV loading dose, then 5 mg/kg tid until able to take PO ⁶⁰	20 mg/kg/day PO in 3 divided doses × 7 days or 10 mg/kg IV loading dose, then 5 mg/kg tid until able to take PO ⁶⁰
Alternative:	Artesunate ^27,74	2.4 mg/kg/dose IV × 3 days, at 0, 12, 24, 48, and 72 hr	2.4 mg/kg/dose IV × 3 days, at 0, 12, 24, 48, and 72 hr
Followed by:	Atovaquone-proguanil, doxycycline, clindamycin, or mefloquine as above	2.4 mg/kg/dose IV × 3 days, at 0, 12, 24, 48, and 72 hr	2.4 mg/kg/dose IV × 3 days, at 0, 12, 24, 48, and 72 hr
*Prevention of relapses: P. vivax* and P. ovale only**
Drug of choice:	Primaquine phosphate ⁷⁰	30 mg base/day PO × 14 days	0.6 mg base/kg/day PO × 14 days
Malaria: Prevention ⁷⁵
Chloroquine-sensitive areas ⁶⁰
Drug of choice	Chloroquine phosphate ^76,77,78	500 mg salt (300 mg base), PO once/wk beginning 1-2 wk before travel to malarious area and 4 wk after leaving	5 mg/kg base once/wk, up to adult dose of 300 mg base beginning 1-2 wk before travel to malarious area and 4 wk after leaving
or	Hydroxychloroquine (Plaquenil) ⁷¹	400 mg (310 mg base) PO once/wk beginning 1-2 wk before travel to malarious area and 4 wk after leaving	5 mg/kg base once/wk, up to adult dose of 310 mg base beginning 1-2 wk before travel to malarious area and 4 wk after leaving
Chloroquine-resistant areas ⁶⁰
Drug of choice:	Atovaquone/proguanil ^62,77,79,80	1 adult tablet PO q day beginning 1-2 days before travel to malarious area and 7 days after leaving	11-20 kg: 1 pediatric tablet PO/day
			21-30 kg: 2 pediatric tablets PO/day
			31-40 kg: 3 pediatric tablets PO/day
			>40 kg: 1 adult tablet PO/day
or	Mefloquine ^67,77,78,81	1 adult tablet PO q day beginning 1-2 wk before travel to malarious area and 4 wk after leaving	<9 kg: 5 mg/kg salt once/wk
			9-19 kg: ¼ tablet once/wk
			19-30 kg: ½ tablet once/wk
			31-45 kg: ¾ tablet once/wk
			>45 kg: 1 tablet once/wk
or	Doxycycline ^7,82	100 mg PO daily	≥8 yr: 2 mg/kg/day, up to 100 mg/day
Alternative for areas with primarily P. vivax:	Primaquine ^7,83	30 mg base PO daily beginning 1-2 days before travel to malarious area and 7-14 days after leaving	0.5 mg/kg base (max 30 mg) daily beginning 1-2 days before travel to malarious area and 7-14 days after leaving
Malaria: Presumptive self-treatment ⁸⁴
Drug of choice:	Atovaquone/proguanil (Malarone) Adult tablets: 50 mg atovaquone/100 mg proguanil Pediatric tablets 62.5 mg atovaquone/25 mg proguanil ⁶²	4 adult tablets PO once daily × 3 days	<5 kg: not indicated
			5-8 kg: 2 pediatric tablets PO daily × 3 days
			9-10 kg: 3 pediatric tablets PO daily × 3 days
			11-20 kg: 1 adult tablet PO daily × 3 days
			21-30 kg: 2 adult tablets PO daily × 3 days
			31-40 kg: 3 adult tablets PO daily × 3 days
			>40 kg: 4 adult tablets PO daily × 3 days
or	Quinine sulfate ⁶³	648 mg salt PO tid × 3-7 days	10 mg salt/kg PO tid × 3-7 days
or	plus Doxycycline ^7,16	100 mg PO bid × 7 days	4 mg/kg/day PO in 2 divided doses × 7 days
or	Mefloquine ^67,68	750 mg PO followed 12 hr later by 500 mg	15 mg/kg PO followed 12 hr later by 10 mg/kg
Microsporidiosis
Ocular (Encephalitozoon hellem, Encephalitozoon cuniculi, Vittaforma corneae [Nosema corneum])
Drug of choice:	Albendazole ^7,85	400 mg PO bid	<10 kg/2 yr: ¹¹
	Albendazole ^7,85	400 mg PO bid	≥2 yr: see adult dosing
	plus Fumagillin ⁸⁶
Intestinal (Enterocytozoon bieneusi, Encephalitozoon [Septata] intestinalis)
*E. bieneusi* ⁸⁷
Drug of choice:	Fumagillin	60 mg/day PO × 14 days in 3 divided doses
*E. intestinalis*
Drug of choice:	Albendazole ^7,85	400 mg PO bid × 21 days	<10 kg/2 yr: ¹¹
Drug of choice:	Albendazole ^7,85	400 mg PO bid × 21 days	≥2 yr: see adult dosing
Disseminated (E. hellem, E. cuniculi, E. intestinalis, Pleistophora sp., Trachipleistophora sp., and Brachiola vesicularum)
Drug of choice: ⁸⁸	Albendazole ^7,85	400 mg PO bid	<10 kg/2 yr: ¹¹
Drug of choice: ⁸⁸	Albendazole ^7,85	400 mg PO bid	≥2 yr: see adult dosing
Mites, see Scabies
Moniliformis moniliformis infection
Drug of choice:	Pyrantel pamoate (OTC) ⁷	11 mg/kg PO once, repeat twice, 2 wk apart	11 mg/kg PO once, repeat twice, 2 wk apart
Naegleria species, see Amebic meningoencephalitis, primary
Necator americanus, see Hookworm infection
*Oesophagostomum bifurcum*
Drug of choice:	See footnote 89
Onchocerca volvulus, see Filariasis
Opisthorchis viverrini, see Fluke infection
Paragonimus westermani, see Fluke infection
Pediculus capitis, Pediculus humanus, Phthirus pubis, see Lice
Pinworm, see Enterobius
Pneumocystis jiroveci (formerly Pneumocystis carinii ) pneumonia (PCP) ⁹⁰
Moderate to severe disease
Drug of choice:	Trimethoprim-sulfamethoxazole (TMP-SMX)	15-20 mg/kg/day TMP component IV in 3-4 divided doses × 21 days (change to PO after clinical improvement)	15-20 mg/kg/day TMP component IV in 3-4 divided doses × 21 days (change to PO after clinical improvement)
Alternative:	Pentamidine	3-4 mg IV daily × 21 days	3-4 mg IV daily × 21 days
or	Primaquine	30 mg base PO daily × 21 days	0.3 mg/kg base PO (max 30 mg) daily × 21 days
or	plus Clindamycin ⁷	600-900 mg IV tid or qid × 21 days, or 300-450 mg PO tid or qid × 21 days (change to PO after clinical improvement)	15-25 mg/kg IV tid or qid × 21 days, or 10 mg/kg PO tid or qid (max 300-450 mg/dose) × 21 days (change to PO after clinical improvement)
Mild to moderate disease
Drug of choice:	Trimethoprim-sulfamethoxazole (TMP-SMX)	320 mg/1600 mg (2 DS tablets) PO tid × 21 days	TMP 15-20 mg/kg/day PO in 3 or 4 doses × 21 days
Alternatives:	Dapsone	100 mg PO daily × 21 days	2 mg/kg/day (max 100 mg) PO × 21 days
Alternatives:	plus Trimethoprim	15 mg/kg/day PO in 3 doses	15 mg/kg/day PO in 3 doses
or	Primaquine	30 mg base PO daily × 21 days	0.3 mg/kg base PO daily (max 30 mg) × 21 days
or	plus Clindamycin	300-450 mg PO tid or qid × 21 days	10 mg/kg PO tid or qid (max 300-450 mg/dose) × 21 days
or	Atovaquone	750 mg PO bid × 21 days	1-3 mo: 30 mg/kg/day PO in 2 doses × 21 days
Primary and secondary prophylaxis ⁹¹
Drug of choice:	Trimethoprim-sulfamethoxazole (TMP-SMX)	1 tablet (single strength or greater) PO daily or 1 DS tablet PO 3 days/wk	TMP 150 mg/m ² in 1-2 doses daily or on 3 consecutive days per wk ⁹²
Alternatives: ⁹¹	Dapsone ⁷	50 mg PO bid, or 100 mg PO daily	2 mg/kg/day (max 100 mg) PO or 4 mg/kg (max 200 mg) PO each wk
or	Dapsone ⁷	50 mg PO daily or 200 mg PO each wk
or	plus Pyrimethamine ⁹³	50 mg PO or 75 mg PO each wk
or	Pentamidine aerosol	300 mg inhaled monthly via Respirgard II nebulizer	≥5 yr: 300 mg inhaled monthly via Respirgard II nebulizer
or	Atovaquone ⁷	1,500 mg/day PO in 1 or 2 doses	1-3 mo: 30 mg/kg/day PO
			4-24 mo: 45 mg/kg/day PO in 2 doses × 21 days
			>24 mo: 30 mg/kg/day PO in 2 doses × 21 days
Roundworm, see Ascariasis
Sappinia diploidea, see Amebic meningoencephalitis, primary
Scabies (Sarcoptes scabiei)
Drug of choice:	5% Permethrin ⁹⁴	Topically, 2× at least 1 wk apart	Topically 2x, 1 wk apart, approved for ≥ 2 mo
Alternative: ^94,95	Ivermectin ^7,94,96	200 µg/kg PO x2 at least 1 wk apart	<15 kg: not indicated
	Ivermectin ^7,94,96	200 µg/kg PO x2 at least 1 wk apart	≥15 kg: see adult dosing
	10% Crotamiton	Topically overnight on days 1, 2, 3, 8	Topically overnight on days 1, 2, 3, 8
Schistosomiasis (Bilharziasis)
**Schistosoma haematobium or S. intercalatum**
Drug of choice:	Praziquantel	40 mg/kg/day PO in 1 or 2 doses × 1 day	40 mg/kg/day PO in 1 or 2 doses × 1 day ³⁶
**Schistosoma japonicum or S. mekongi**
Drug of choice:	Praziquantel	60 mg/kg/day PO in 2 or 3 doses × 1 day	60 mg/kg/day PO in 3 doses × 1 day ³⁶
*Schistosoma mansoni*
Drug of choice:	Praziquantel	40 mg/kg/day PO in 1 or 2 doses × 1 day	40 mg/kg/day PO in 1 or 2 doses × 1 day ³⁶
Alternative:	Oxamniquine ^97,98	15 mg/kg PO once	20 mg/kg/day PO in 2 doses × 1 day
Sleeping sickness, see Trypanosomiasis
Strongyloidiasis (Strongyloides stercoralis)
Drug of choice: ⁹⁹	Ivermectin	200 µg/kg/day PO × 2 days	<15 kg: not indicated
Drug of choice: ⁹⁹	Ivermectin	200 µg/kg/day PO × 2 days	≥15 kg: see adult dosing
Alternative:	Albendazole ^7,100	400 mg PO bid × 7 days	<10 kg/2 yr: ¹¹
Alternative:	Albendazole ^7,100	400 mg PO bid × 7 days	≥2 yr: see adult dosing
Tapeworm infection
Adult (intestinal stage)
Diphyllobothrium latum (fish), Taenia saginata (beef), Taenia solium (pork), Dipylidium caninum (dog)
Drug of choice:	Praziquantel ⁷	5-10 mg/kg PO once	5-10 mg/kg PO once ³⁶
Alternative:	Niclosamide	2 g PO once	50 mg/kg PO once
Hymenolepis nana (dwarf tapeworm)
Drug of choice:	Praziquantel ⁷	25 mg/kg PO once	25 mg/kg PO once ³⁶
Alternative:	Niclosamide ¹⁰¹	2 g PO daily × 7 days	11-34 kg: 1 g PO on day 1, then 500 mg/day PO × 6 days
Alternative:	Niclosamide ¹⁰¹	2 g PO daily × 7 days	>34 kg: 1.5 g PO on day 1, then 1 g/day PO × 6 days
Larval (tissue stage)
Echinococcus granulosus (hydatid disease cystic echinococcosis)
Drug of choice: ¹⁰²	Albendazole ⁷	400 mg PO bid × 1-6 mo	<10 kg/2 yr: 5-7.5 mg/kg PO bid (max 400 mg) ¹¹
Drug of choice: ¹⁰²	Albendazole ⁷	400 mg PO bid × 1-6 mo	≥2 yr: 5-7.5 mg/kg PO bid (max 400 mg) × 1-6 mo
Echinococcus multilocularis (alveolar echinococcosis)
Treatment of choice:	See footnote 103
Taenia solium (cysticercosis)
Treatment of choice: ¹⁰⁴	Albendazole	400 mg bid PO × 8-30 days; can be repeated as necessary	<10 kg/2 yr: 7.5 mg/kg PO bid × 8-30 days; can be repeated as necessary ¹¹
	Albendazole	400 mg bid PO × 8-30 days; can be repeated as necessary	≥2 yr: 7.5 mg/kg PO (max 400 mg) bid × 8-30 days; can be repeated as necessary
	plus Steroids
Alternative:	Praziquantel ⁷	50 mg/kg/day PO in 3 divided doses × 15 days	50 mg/kg/day PO in 3 divided doses × 15 days ³⁶
or	Surgical removal
Toxocariasis, see Visceral larva migrans
Toxoplasmosis (Toxoplasma gondii) ¹⁰⁵
Drug of choice: ^106,107	Pyrimethamine ¹⁰⁸	200 mg PO × 1, then 50-75 mg/day × 3-6 wk	2 mg/kg/day × 3 days, then 1 mg/kg/day (max 25 mg/day) × 3-6 wk ¹⁰⁹
	plus Sulfadiazine	1.5 g PO qid × 3-6 wk	100-200 mg/kg/day in 4 divided doses × 3-6 wk
	or plus Clindamycin	1.8-2.4 g/day IV or PO in 3-4 doses × 3-6 wk	5-7.5 mg/kg IV or PO tid or qid (max 600 mg/dose) × 3-6 wk
	or plus Atovaquone	1,500 mg PO bid	1,500 mg PO bid
Alternative:	Trimethoprim-sulfamethoxazole (TMP-SMX) ⁷	15-20 mg/kg/day TMP component PO or IV in 3-4 divided doses × 3-6 wk	15-20 mg/kg TMP component PO or IV in 3 or 4 doses × 3-6 wk
Trichinellosis (Trichinella spiralis)
Drug of choice:	Steroids for severe symptoms	Prednisone 30-60 mg PO daily × 10-15 days
	plus Albendazole ⁷	400 mg PO bid × 8-14 days	<10 kg/2 yr: ¹¹
	plus Albendazole ⁷	400 mg PO bid × 8-14 days	≥2 yr: see adult dosing
Alternative:	Mebendazole ⁷	200-400 mg PO tid × 3 days, then 400-500 mg PO tid × 10 days	200-400 mg PO tid × 3 days, then 400-500 mg PO tid × 10 days ¹²
Trichomoniasis (Trichomonas vaginalis)
Drug of choice: ¹¹⁰	Metronidazole	2 g PO once or 500 mg PO bid × 7 days	15 mg/kg/day PO in 3 doses × 7 days
or	Tinidazole ⁴	2 g PO once	50 mg/kg PO once (max 2 g)
Trichostrongylus infection
Drug of choice:	Pyrantel pamoate ⁷	11 mg/kg base PO once (max 1 g)	11 mg/kg PO once (max 1 g)
Alternative:	Mebendazole ⁷	100 mg PO bid × 3 days	100 mg PO bid × 3 days ¹²
or	Albendazole ⁷	400 mg PO once	<10 kg/2 yr: ¹¹
or	Albendazole ⁷	400 mg PO once	≥2 yr: 15 mg/kg/day PO (max 800 mg) × 1-6 mo
*Trichuriasis ( Trichuris trichiura,* whipworm)**
Drug of choice:	Mebendazole	100 mg PO bid × 3 days	100 mg PO bid × 3 days ¹²
Alternative:	Albendazole ⁷	400 mg PO × 3 days	<10 kg/2 yr: ¹¹
Alternative:	Albendazole ⁷	400 mg PO × 3 days	≥2 yr: see adult dosing
or	Ivermectin ⁷	200 µg/kg PO daily × 3 days	<15 kg: not indicated
or	Ivermectin ⁷	200 µg/kg PO daily × 3 days	≥15 kg: see adult dosing
Trypanosomiasis ¹¹¹
Trypanosoma cruzi (American trypanosomiasis, Chagas disease)
Drug of choice:	Benznidazole ²⁷	5-7 mg/kg/day PO in 2 divided doses × 60 days	≤12 yr: 5-7.5 mg/kg/day PO in 2 divided doses × 60 days
Drug of choice:	Benznidazole ²⁷	5-7 mg/kg/day PO in 2 divided doses × 60 days	>12 yr: see adult dosing
Alternative:	Nifurtimox ^27,112	8-10 mg/kg/day PO in 3-4 doses × 90 days	≤10 yr: 15-20 mg/kg/day PO in 3-4 doses × 90 days
			11-16 yr: 12.5-15 mg/kg/day in 3-4 doses × 90 days
			>16 yr: see adult dosing
Trypanosoma brucei gambiense (West African trypanosomiasis, sleeping sickness)
Hemolymphatic stage
Drug of choice: ¹¹³	Pentamidine isethionate ⁷	4 mg/kg/day IM × 7-10 days	4 mg/kg/day IM or IV × 7-10 days
Alternative:	Suramin ²⁷	100 mg (test dose) IV, then 1 g IV on days 1, 3, 7, 14, and 21	2 mg/kg (test dose) IV, then 20 mg/kg IV on days 1, 3, 7, 14, and 21
Late disease with CNS involvement
Drug of choice:	Eflornithine ^27,114	100 mg/kg IV qid × 14 days	100 mg/kg IV qid × 14 days
Alternative:	Melarsoprol ^27,115	2-3.6 mg/kg (max 200 mg) daily IV (progressively increased during series) × 3 days. After 7 days, 3.6 mg/kg daily × 3 days. After 7 days, give a 3rd series of 3.6 mg/kg daily × 3 days.	2-3.6 mg/kg (max 200 mg) daily IV (progressively increased during series) × 3 days. After 7 days, 3.6 mg/kg daily × 3 days. After 7 days, give a 3rd series of 3.6 mg/kg daily × 3 days.
Trypanosoma brucei rhodesiense (East African trypanosomiasis, sleeping sickness)
Hemolymphatic stage
Drug of choice:	Suramin ²⁷	100 mg (test dose) IV, then 1 g IV on days 1, 3, 7, 14, and 21	2 mg/kg (test dose), then 20 mg/kg IV on days 1, 3, 7, 14, and 21
Late disease with CNS involvement
Drug of choice:	Melarsoprol ^27,114	2-3.6 mg/kg (max 200 mg) daily IV (progressively increased during series) × 3 days. After 7 days, 3.6 mg/kg daily × 3 days. After 7 days, give a 3rd series of 3.6 mg/kg daily × 3 days.	2-3.6 mg/kg (max 200 mg) daily IV (progressively increased during series) × 3 days. After 7 days, 3.6 mg/kg daily × 3 days. After 7 days, give a 3rd series of 3.6 mg/kg daily × 3 days.
Visceral larva migrans (Toxocariasis) ¹¹⁶
Drugs of choice:	Albendazole ⁷	400 mg PO bid × 5 days	<10 kg/2 yr: ¹¹
Drugs of choice:	Albendazole ⁷	400 mg PO bid × 5 days	≥2 yr: see adult dosing
or	Mebendazole ⁷	100-200 mg PO bid × 5 days	100-200 mg PO bid × 5 days ¹²
Whipworm, see Trichuriasis
Wuchereria bancrofti, see Filariasis

CDC, Centers for Disease Control and Prevention; CNS, central nervous system; CSF, cerebrospinal fluid; DS, double strength; ECG, electrocardiography; FDA, U.S. Food and Drug Administration; GI, gastrointestinal; HAART, highly active antiretroviral therapy; SMX, sulfamethoxazole; TMP, trimethoprim; WHO, World Health Organization.

1 For treatment of keratitis caused by Acanthamoeba, 0.02% topical polyhexamethylene biguanide (PHMB) and 0.02% chlorhexidine have been successfully used individually and in combination in a large number of patients (Tabin G, et al: Cornea 20:757, 2001; Wysenbeek YS, et al: Cornea 19:464, 2000). The expected treatment course is 6-12 mo. PHMB is no longer available from Leiter's Park Avenue Pharmacy but is available from the O'Brien Pharmacy (1-800-627-4360; distributes in many states) and the Greenpark Pharmacy (1-713-432-9855; Texas only). Combinations with either 0.1% propamidine isethionate (Brolene) or hexamidine (Desmodine) have been used (Seal DV: Eye 17:893, 2003) successfully, but these are not available in the United States. Neomycin is no longer recommended due to high levels of resistance ( Acanthamoeba keratitis: Treatment guidelines from The Medical Letter 143, 8/1/2013). In addition, the combination of chlorhexidine, natamycin (pimaricin), and debridement also has been successful (Kitagawa K, et al: Jpn J Ophthalmol 47:616, 2003).

2 The drug is not available commercially but can be compounded by Expert Compounding Pharmacy, 6744 Balboa Blvd, Lake Balboa, CA 91406 (1-800-247-9767 or 1-818-988-7979 or info@expertpharmacy.org ).

3 The drug is not available commercially in the United States.

4 A nitroimidazole similar to metronidazole, tinidazole was approved by the FDA in 2004 and appears to be as effective and better tolerated than metronidazole. It should be taken with food to minimize GI adverse effects. For children and patients unable to take tablets, a pharmacist may crush the tablets and mix them with cherry syrup (Humco, and others). The syrup suspension is good for 7 days at room temperature and must be shaken before use. Ornidazole, a similar drug, is also used outside the United States.

5 Nitazoxanide is FDA approved as a pediatric oral suspension for treatment of Cryptosporidium in immunocompetent children ≥ 1 yr of age. It has also been used in some small studies for Balantidium coli infection. It may also be effective for mild to moderate amebiasis (Diaz E, et al: Am J Trop Med Hyg 68:384, 2003; Rossignol JF, et al: Trans R Soc Trop Med Hyg 101:1025, 2007). Nitazoxanide is available in 500 mg tablets and an oral suspension; it should be taken with food.

6 Naegleria infection has been treated successfully with IV and intrathecal use of both amphotericin B and miconazole plus rifampin and with amphotericin B, rifampin, and ornidazole (Seidel J, et al: N Engl J Med 306:346, 1982; Jain R, et al: Neurol India 50:470, 2002). Other reports of successful therapy are less-well documented.

7 An approved drug, but usage is considered off-label for this condition by the FDA.

8 If you have a patient with suspected free-living amoeba infection, please contact the CDC Emergency Operations Center at 1-800-CDC-INFO to consult with a CDC expert regarding the use of this drug. Miltefosine has been reported to successfully treat primary amebic meningoencephalitis due to Naegleria fowleri, although controlled trials have not been conducted (Linam M, et al: Pediatrics 135:e744-e748, 2015).

9a Strains of Acanthamoeba isolated from fatal granulomatous amebic encephalitis are usually susceptible in vitro to pentamidine, ketoconazole, flucytosine, and (less so) amphotericin B. Chronic Acanthamoeba meningitis has been successfully treated in two children with a combination of oral trimethoprim-sulfamethoxazole, rifampin, and ketoconazole (Singhal T, et al: Pediatr Infect Dis J 20:623, 2001), and in an AIDS patient with fluconazole, sulfadiazine, and pyrimethamine combined with surgical resection of the CNS lesion (Seijo Martinez M, et al: J Clin Microbiol 38:3892, 2000). Disseminated cutaneous infection in an immunocompromised patient has been treated successfully with IV pentamidine isethionate, topical chlorhexidine, and 2% ketoconazole cream, followed by oral itraconazole (Slater CA, et al: N Engl J Med 331:85, 1994).

9b A free-living leptomyxid ameba that causes subacute to fatal granulomatous CNS disease. Several cases of Balamuthia encephalitis have been successfully treated with flucytosine, pentamidine, fluconazole, and sulfadiazine plus either azithromycin or clarithromycin (phenothiazines were also used) combined with surgical resection of the CNS lesion (Deetz TR, et al: Clin Infect Dis 37:1304, 2003; Jung S, et al: Arch Pathol Lab Med 128:466, 2004). Case reports and in vitro data suggest miltefosine may have some antiamebic activity (Aichelburg AC, et al: Emerg Infect Dis 14:1743, 2008; Martinez DY, et al: Clin Infect Dis 51:e7, 2010; Schuster FL, et al: J Eukaryot Microbiol 53:121, 2006). Miltefosine (Impavido) is now commercially available. Contact the Centers for Disease Control/Agency for Toxic Substances Disease Registry at 1-770-488-7100 or 1-800-232-4636 (main number) for guidance on treatment.

10 A free-living ameba not previously known to be pathogenic to humans. It has been successfully treated with azithromycin, IV pentamidine, itraconazole, and flucytosine combined with surgical resection of the CNS lesion (Gelman BB, et al: J Neuropathol Exp Neurol 62:990, 2003).

11 Limited data in children < 2 yr but has been used successfully for treatment of cutaneous larva migrans in children as young as 8 mo at a dose of 200 mg daily × 3 days (Black MD, et al: Australas J Dermatol 51:281-284, 2010). The WHO also recommends albendazole in children < 2 yr for treatment of taeniasis, strongyloidiasis, filariasis, hookworms, roundworms, pinworms, and threadworms.

12 Limited safety data in children < 2 yr of age.

13 Most patients have a self-limited course and recover completely. Analgesics, corticosteroids, and careful removal of CSF at frequent intervals can relieve symptoms from increased intracranial pressure (Lo Re V III, Gluckman SJ: Am J Med 114:217, 2003). No anthelmintic drug is proven to be effective, and some patients have worsened with therapy (Slom TJ, et al: N Engl J Med 346:668, 2002). Mebendazole or albendazole and a corticosteroid appeared to shorten the course of infection (Sawanyawisuth K, Sawanyawisuth K: Trans R Soc Trop Med Hyg 102:990, 2008; Chotmongkol V, et al: Am J Trop Med Hyg 81:443, 2009).

14 (Repiso Ortega A, et al: Gastroenterol Hepatol 26:341, 2003.) Successful treatment of a patient with anisakiasis with albendazole has been reported (Moore DA, et al: Lancet 360:54, 2002).

15 Exchange transfusion has been used in severely ill patients and those with high (>10%) parasitemia (Hatcher JC, et al: Clin Infect Dis 32:1117, 2001). Clindamycin and quinine is the preferred therapy for severely ill patients. In patients who were not severely ill, combination therapy with atovaquone and azithromycin was as effective as clindamycin and quinine and may have been better tolerated (Krause PJ, et al: N Engl J Med 343:1454, 2000). Highly immunosuppressed patients should be treated for a minimum of 6 wk and at least 2 wk past the last positive smear (Krause PJ, et al: Clin Infect Dis 46:370, 2008). High doses of azithromycin (600-1,000 mg) have been used in combination with atovaquone for the treatment of immunocompromised patients (Weiss LM, et al: N Engl J Med 344:773, 2001). Resistance to atovaquone plus azithromycin has been reported in immunocompromised patients treated with a single subcurative course of this regimen (Wormser GP, et al: Clin Infect Dis 50:381, 2010). Most asymptomatic patients do not require treatment unless parasitemia persists > 3 mo (Wormser GP, et al: Clin Infect Dis 43:1089-1134, 2006).

16 Use of tetracyclines is contraindicated in pregnancy and in children younger than 8 yr old.

17 No drugs have been consistently demonstrated to be effective. The combination of albendazole 37 mg/kg/day PO and high-dose steroids has been used successfully (Peters JM, et al: Pediatrics 129:e806, 2012; Haider S: Emerg Infect Dis 18:347, 2012). Albendazole 25 mg/kg/day PO × 20 days started as soon as possible (up to 3 days after possible infection) might prevent clinical disease and is recommended for children with known exposure, as in the setting of ingestion of raccoon stool or contaminated soil (Murray WJ, Kazacos KR: Clin Infect Dis 39:1484, 2004). Mebendazole, levamisole, or ivermectin could be tried if albendazole is not available. Ocular baylisascariasis has been treated successfully using laser photocoagulation therapy to destroy the intraretinal larvae.

18 Clinical significance of these organisms is controversial; metronidazole 750 mg tid × 10 days, iodoquinol 650 mg tid × 20 days, or trimethoprim-sulfamethoxazole 1 DS tablet bid × 7 days has been reported to be effective (Stenzel DJ, Borenam PFL: Clin Microbiol Rev 9:563, 1996; Ok UZ, et al: Am J Gastroenterol 94:3245, 1999). Metronidazole resistance may be common (Haresh K, et al: Trop Med Int Health 4:274, 1999). Nitazoxanide has been effective in children (Diaz E, et al: Am J Trop Med Hyg 68:384, 2003).

19 Nitazoxanide has not consistently been shown to be superior to placebo in HIV-infected patients (Amadi B, et al: Lancet 360;1375, 2002). For HIV-infected patients, potent antiretroviral therapy (ART) is the mainstay of treatment. Nitazoxanide 500-1,000 mg for 14 days, paromomycin 500 mg 4 times daily × 14-21 days, or a combination of paromomycin and azithromycin may be tried to decrease diarrhea and recalcitrant malabsorption of antimicrobial drugs, which can occur with chronic cryptosporidiosis (Pantenburg B, et al: Expert Rev Anti Infect Ther 7:385, 2009).

20 Albanese G, et al: Int J Dermatol 40:67, 2001.

21 HIV-infected patients may need a higher dosage and long-term maintenance (Kansouzidou A, et al: J Trav Med 11:61, 2004).

22 Norberg A, et al: Clin Microbiol Infect 9:65, 2003.

23 Treatment of choice is slow extraction of worm combined with wound care ( MMWR Morbid Mortal Wkly Rep 60:1450, 2011). Instructions for this can be found at https://www.cdc.gov/parasites/guineaworm/treatment.html . Ten days of treatment with metronidazole 250 mg tid in adults and 25 mg/kg/day in 3 doses in children is not curative, but it decreases inflammation and facilitates removal of the worm. Mebendazole 400-800 mg/day × 6 days has been reported to kill the worm directly.

24 Because all family members are usually infected, treatment of the entire household is recommended.

25 Antihistamines or corticosteroids may be required to decrease allergic reactions due to disintegration of microfilariae from treatment of filarial infections, especially those caused by Loa loa. Endosymbiotic Wolbachia bacteria may have a role in filarial development and host response and may represent a new target for therapy. Treatment with doxycycline 100 or 200 mg/day × 4-6 wk in lymphatic filariasis and onchocerciasis has resulted in substantial loss of Wolbachia with subsequent blocking of microfilariae production and absence of microfilaria when followed for 24 mo after treatment (Hoerauf A, et al: Med Microbiol Immunol 192:211, 2003; Hoerauf A, et al: BMJ 326:207, 2003).

26 Most symptoms caused by adult worm. Single-dose combination of albendazole (400 mg) with either ivermectin (200 µg/kg) or diethylcarbamazine (6 mg/kg) is effective for reduction or suppression of Wuchereria bancrofti microfilaria but does not kill the adult forms (Addiss D, et al: Cochrane Database Syst Rev (1):CD003753, 2004).

27 This drug is not FDA approved and not commercially available but is available under IND application through the CDC Drug Service (CDC Drug Service, Division of Scientific Resources, telephone at 1-404-639-3670.

28 DEC is contraindicated in patients coinfected with Oncocerca volvulus due to risk of a life-threatening Mazzotti reaction and in patients with Loa loa infection and microfilaria levels ≥ 8,000 mm ³ due to risk of encephalopathy and renal failure. Some experts use a cutoff of ≥ 2,500 mm ³ .

29 For patients with microfilaria in the blood, Medical Letter consultants would start with a lower dosage and scale up: day 1, 50 mg; day 2, 50 mg tid; day 3, 100 mg tid; day 4-14, 6 mg/kg in 3 doses (for Loa loa, day 4-14, 9 mg/kg in 3 doses). Multidose regimens have been shown to provide more rapid reduction in microfilaria than single-dose diethylcarbamazine, but microfilaria levels are similar 6-12 mo after treatment (Andrade LD, et al: Trans R Soc Trop Med Hyg 89:319, 1995; Simonsen PE, et al: Am J Trop Med Hyg 53:267, 1995). A single dose of 6 mg/kg is used in endemic areas for mass treatment (Figueredo-Silva J, et al: Trans R Soc Trop Med Hyg 90:192, 1996; Noroes J, et al: Trans R Soc Trop Med Hyg 91:78, 1997).

30 In heavy infections with Loa loa, rapid killing of microfilariae can provoke an encephalopathy. Apheresis has been reported to be effective in lowering microfilarial counts in patients heavily infected with Loa loa (Ottesen ES: Infect Dis Clin North Am 7:619, 1993). Albendazole or ivermectin has also been used to reduce microfilaremia; albendazole is preferred because of its slower onset of action and lower risk for encephalopathy (Klion AD, et al: J Infect Dis 168:202, 1993; Kombila M, et al: Am J Trop Med Hyg 58:458, 1998). Albendazole may be useful for treatment of loiasis when diethylcarbamazine is ineffective or cannot be used, but repeated courses may be necessary (Klion AD, et al: Clin Infect Dis 29:680, 1999). Diethylcarbamazine, 300 mg once/wk, has been recommended for prevention of loiasis (Nutman TB, et al: N Engl J Med 319:752, 1988).

31 Diethylcarbamazine has no effect. Ivermectin 200 µg/kg once has been effective.

32 Doxycycline is preferred for strains that carry Wolbachia bacteria. Combination therapy with diethylcarbamazine and mebendazole and monotherapy with mebendazole have been used successfully in strains that do not carry Wolbachia. Evidence is limited, and optimal therapy is uncertain. Ivermectin and albendazole appear to be ineffective.

33 Diethylcarbamazine is potentially curative because of activity against both adult worms and microfilariae. Ivermectin is only active against microfilariae. ( The Medical Letter: Drugs for parasitic infections, vol 11, 2013.)

34 Relapse occurs and can be treated with diethylcarbamazine.

35 Annual treatment with ivermectin, 150 µg/kg, can prevent blindness from ocular onchocerciasis (Mabey D, et al: Ophthalmology 103:1001, 1996). Ivermectin kills only the microfilaria but not the adult worms; emerging evidence suggests doxycycline is effective in killing adult worms and sterilizing females. The recommended regimen from the CDC is doxycycline 100-200 mg PO daily for 6 wk begun 1 wk after a dose of ivermectin is given to reduce the microfilaria burden. Diethylcarbamazine and suramin were formerly used for treatment of this disease but should no longer be used owing to the availability of less toxic therapies.

36 Limited safety data in children < 4 yr old but has been used in mass prevention campaigns with no reported adverse effects.

37 Unlike infections with other flukes, Fasciola hepatica infections do not respond to praziquantel. Triclabendazole may be safe and effective, but data are limited (Graham CS, et al: Clin Infect Dis 33:1, 2001). In the United States, the drug is not approved by the FDA and is not yet commercially available. However, it is available to U.S.-licensed physicians through the CDC Drug Service, under a special protocol, which requires that both the CDC and FDA agree that the drug is indicated for treatment of a particular patient. Providers should contact the CDC Drug Service, Division of Scientific Resources, at 1-404-639-3670. It is available from Victoria Pharmacy, Zurich, Switzerland ( www.pharmaworld.com ). The drug should be given with food for better absorption. A single study has found that nitazoxanide has limited efficacy for treating fascioliasis in adults and children (Favennec L, et al: Aliment Pharmacol Ther 17:265, 2003).

38 Richter J, et al: Curr Treat Options Infect Dis 4:313, 2002.

39 MacLean JD, et al: Lancet 347:154, 1996.

40 Triclabendazole may be effective in a dosage of 5 mg/kg once/day × 3 days or 10 mg/kg bid ^× 1 day (Calvopiña M, et al: Trans R Soc Trop Med Hyg 92:566, 1998). In the United States, it is not approved by the FDA and is not yet commercially available. However, it is available to U.S.-licensed physicians through the CDC Drug Service, under a special protocol, which requires both the CDC and FDA to agree that the drug is indicated for treatment of a particular patient. Providers should contact the CDC Drug Service, Division of Scientific Resources, at 1-404-639-3670. The drug is available from Victoria Pharmacy, Zurich, Switzerland; Phone, 41 43 344 60 60; FAX, 41 43 344 60 69; http://www.pharmaworld.com ; e-mail, info@pharmaworld.com .

41 Albendazole 400 mg daily × 5 days alone or in combination with metronidazole may also be effective (Hall A, Nahar Q: Trans R Soc Trop Med Hyg 87:84, 1993; Dutta AK, et al: Indian J Pediatr 61:689, 1994; Cacopardo B, et al: Clin Ter 146:761, 1995). Combination treatment with standard doses of metronidazole and quinacrine given for 3 wk has been effective for a small number of refractory infections (Nash TE, et al: Clin Infect Dis 33:22, 2001). In one study, nitazoxanide was used successfully in high doses to treat a case of Giardia infection resistant to metronidazole and albendazole (Abboud P, et al: Clin Infect Dis 32:1792, 2001).

42 Not absorbed; may be useful for treatment of giardiasis in pregnancy.

43 de Gorgolas M, et al: J Travel Med 10:358, 2003. All patients should be treated with a medication regardless of whether surgery is attempted.

44 Eberhard ML, Busillo C: Am J Trop Med Hyg 61:51, 1999; Wilson ME, et al: Clin Infect Dis 32:1378, 2001.

45 Consultation with physicians experienced in management of this disease is recommended. To maximize effectiveness and minimize toxicity, the choice of drug, dosage, and duration of therapy should be individualized based on the region of disease acquisition, likely infecting species, number, significance and location of lesions, and host factors such as immune status (Murray HW: Lancet 366:1561, 2005; Aronson N, et al: Clin Infect Dis 63:202, 2016). Some of the listed drugs and regimens are effective only against certain Leishmania species/strains and only in certain areas of the world (Sundar S, Chakravarty J: Expert Opin Pharmacother 14:53, 2013).

46 Visceral infection is most commonly caused by the Old World species Leishmania donovani (kala-azar) and Leishmania infantum and the New World species Leishmania chagasi. Treatment duration may vary based on symptoms, host immune status, species, and area of the world where infection was acquired. Liposomal amphotericin B is the treatment of choice in the IDSA leishmaniasis guidelines (Aronson N, et al: Clin Infect Dis 63:202, 2016).

47 Three lipid formulations of amphotericin B have been used for treatment of visceral leishmaniasis. Largely based on clinical trials in patients infected with Leishmania infantum, the FDA approved liposomal amphotericin B (AmBisome) for treatment of visceral leishmaniasis (Meyerhoff A: Clin Infect Dis 28:42, 1999). Amphotericin B lipid complex (Abelcet) and amphotericin B cholesteryl sulfate (Amphotec) have also been used with good results but are considered investigational for this condition by the FDA.

48 The FDA-approved dosage regimen for immunocompromised patients (e.g., HIV infected) is 4 mg/kg/day on days 1-5 and 4 mg/kg/day on days 10, 17, 24, 31, and 38. The relapse rate is high; maintenance therapy may be indicated, but there is no consensus as to dosage or duration. (Russo R, Nigro LC, Minniti S, et al: Visceral leishmaniasis in HIV infected patients: treatment with high dose liposomal amphotericin B [AmBisome], J Infect 32:133-137, 1996).

49 For treatment of kala-azar in adults in India, oral miltefosine 100 mg/day (~205 mg/kg/day) for 3-4 wk was 97% effective after 6 mo (Jha TK, et al: N Engl J Med 341:1795, 1999; Sangraula H, et al: J Assoc Physicians India 51:686, 2003). GI adverse effects are common, and the drug is contraindicated in pregnancy. The dose of miltefosine in an open-label trial in children in India was 2.5 mg/kg/day × 28 days (Bhattacharya SK, et al: Clin Infect Dis 38:217, 2004). Miltefosine (Impavido) has been FDA approved for treatment of leishmaniasis due to Leishmania donovani; cutaneous leishmaniasis due to L. braziliensis , L. guyanensis , and L. panamensis; and mucosal leishmaniasis due to L. braziliensis since 2014 and is now commercially available.

50 May be repeated or continued; a longer duration may be needed for some patients (Herwaldt BL: Lancet 354:1191, 1999).

51 Cutaneous infection is most commonly caused by the Old World species Leishmania major and Leishmania tropica and the New World species Leishmania mexicana, Leishmania (Viannia) braziliensis, and others. Treatment duration may vary based on symptoms, host immune status, species, and area of the world where infection was acquired.

52 In a placebo-controlled trial in patients 12 yr old and older, oral miltefosine was effective for the treatment of cutaneous leishmaniasis caused by Leishmania (Viannia) panamensis in Colombia but not L. (V.) braziliensis in Guatemala at a dosage of about 2.5 mg/kg/day for 28 days. “Motion sickness,” nausea, headache, and increased creatinine were the most frequent adverse effects (Soto J, et al: Clin Infect Dis 38:1266, 2004). For treatment of L. major cutaneous lesions, a study in Saudi Arabia found that oral fluconazole, 200 mg once/day × 6 wk, appeared to speed healing (Alrajhi AA, et al: N Engl J Med 346:891, 2002).

53 At this dosage, pentamidine has been effective against leishmaniasis in Colombia, where the likely organism was L. (V.) panamensis (Soto-Mancipe J, et al: Clin Infect Dis 16:417, 1993; Soto J, et al: Am J Trop Med Hyg 50:107, 1994); its effect against other species is not well established. Updated based on Leishmania practice guidelines (Aronson N, et al: Clin Infect Dis 63:202-264, 2016).

54 Topical paromomycin should be used only in geographic regions where cutaneous leishmaniasis species have low potential for mucosal spread. A formulation of 15% paromomycin/12% methylbenzethonium chloride (Leshcutan) in soft white paraffin for topical use has been reported to be partially effective in some patients against cutaneous leishmaniasis due to L. major in Israel and against L. mexicana and L. (V.) braziliensis in Guatemala, where mucosal spread is very rare (Arana BA, et al: Am J Trop Med Hyg 65:466, 2001). The methylbenzethonium is irritating to the skin; lesions may worsen before they improve.

55 Mucosal infection is most commonly due to the New World species L. (V.) braziliensis, L. (V.) panamensis, or L. (V.) guyanensis. Treatment duration may vary based on symptoms, host immune status, species, and area of the world where infection was acquired

56 Yoon KS, et al: Arch Dermatol 139:994, 2003.

57 A second application is recommended 1 wk later to kill hatching progeny. Lice are increasingly demonstrating resistance to pyrethrins and permethrin (Meinking TL, et al: Arch Dermatol 138:220, 2002). Ivermectin lotion 0.5% was approved by the FDA in 2012 for treatment of head lice in persons 6 mo of age and older. It is not ovicidal, but it appears to prevent nymphs from surviving. It is effective in most patients when given as a single application on dry hair without nit combing ( www.cdc.gov/parasites/lice/head/treatment.html ).

58 Ivermectin is effective against adult lice but has no effect on nits (Jones KN, English JC III: Clin Infect Dis 36:1355, 2003).

59 For infestation of eyelashes with Phthirus pubis lice, use petrolatum; TMP-SMX has also been used (Meinking TL: Curr Probl Dermatol 24:157, 1996). For pubic lice, treat with 5% permethrin or ivermectin as for scabies. TMP-SMX has also been effective, together with permethrin for head lice (Hipolito RB, et al: Pediatrics 107:E30, 2001).

60 Chloroquine-resistant P. falciparum occurs 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, Saudi Arabia, and Iran). For treatment of multidrug-resistant P. falciparum in Southeast Asia, especially Thailand, where resistance to mefloquine is frequent, atovaquone/proguanil, artesunate plus mefloquine, or artemether plus mefloquine may be used (Luxemburger JC, et al: Trans R Soc Trop Med Hyg 88:213, 1994; Karbwang J, et al: Trans R Soc Trop Med Hyg 89:296, 1995).

61 Uncomplicated or mild malaria may be treated with oral drugs.

62 To enhance absorption and reduce nausea and vomiting, it should be taken with food or a milky drink. Safety in pregnancy is unknown, and use is generally not recommended. In a few small studies, outcomes were normal in women treated with the combination in the second and third trimesters (Paternak B, et al: Arch Intern Med 171:259, 2011; Boggild AK, et al: Am J Trop Med Hyg 76:208, 2007). The drug should not be given to patients with severe renal impairment (creatinine clearance < 30 mL/min). There have been isolated case reports of resistance in P. falciparum in Africa, but Medical Letter consultants do not believe there is a high risk for acquisition of Malarone-resistant disease (Schwartz E, et al: Clin Infect Dis 37:450, 2003; Farnert A, et al: BMJ 326:628, 2003; Kuhn S, et al: Am J Trop Med Hyg 72:407, 2005; Happi C, et al: Malar J 5:82, 2006).

63 Although approved for once-daily dosing, Medical Letter consultants usually divide the dose into 2 doses to decrease nausea and vomiting.

64 In Southeast Asia, relative resistance to quinine has increased and treatment should be continued for 7 days.

65 For use in pregnancy.

66 Lell B, Kremsner PG: Antimicrob Agents Chemother 46:2315, 2002.

67 At this dosage, adverse effects, including nausea, vomiting, diarrhea, dizziness, a disturbed sense of balance, toxic psychosis, and seizures can occur. Mefloquine should not be used for treatment of malaria in pregnancy unless there is no other treatment option, because of an increased risk for stillbirth (Nosten F, et al: Clin Infect Dis 28:808, 1999). It should be avoided for treatment of malaria in persons with active depression or with a history of psychosis or seizures and should be used with caution in persons with psychiatric illness. Mefloquine can be given to patients taking β blockers if they do not have an underlying arrhythmia; it should not be used in patients with conduction abnormalities. Mefloquine should not be given together with quinine, quinidine, or halofantrine, and caution is required in using quinine, quinidine, or halofantrine to treat patients with malaria who have taken mefloquine for prophylaxis. Resistance to mefloquine has been reported in some areas, such as the Thailand-Myanmar and Thailand-Cambodia borders and in the Amazon basin, where 25 mg/kg should be used. In the United States, a 250 mg tablet of mefloquine contains 228 mg mefloquine base. Outside the United States, each 275 mg tablet contains 250 mg base.

68 P. falciparum with resistance to mefloquine is a significant problem in the malarious areas of Thailand and in areas of Myanmar and Cambodia that border on Thailand. It has also been reported on the borders between Myanmar and China, Laos and Myanmar, and in Southern Vietnam. In the United States, a 250 mg tablet of mefloquine contains 228 mg mefloquine base. Outside the United States, each 275 mg tablet contains 250 mg base.

69 P. vivax with decreased susceptibility to chloroquine is a significant problem in Papua New Guinea and Indonesia. There are also a few reports of resistance from Myanmar, India, the Solomon Islands, Vanuatu, Guyana, Brazil, Colombia, and Peru.

70 Primaquine phosphate can cause hemolytic anemia, especially in patients whose red cells are deficient in glucose-6-phosphate dehydrogenase (G6PD). This deficiency is most common in African, Asian, and Mediterranean peoples. Patients should be screened for G6PD deficiency before treatment. Primaquine should not be used during pregnancy.

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 (Miller KD, et al: N Engl J Med 321:65, 1989).

73 Continuous ECG, blood pressure, and glucose monitoring is recommended, especially in pregnant women and young children. For problems with quinidine availability, call the manufacturer (Eli Lilly, 1-800-545-5979) or the CDC Malaria Hotline (1-770-488-7788). 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 hr of parenteral treatment is required, the quinine or quinidine dose should be reduced by 30–50%.

74 Oral artesunate is not available in the United States; the IV formulation is available through the CDC Malaria Branch under an investigational new drug (IND) for patients with severe disease who do not have timely access or cannot tolerate, or fail to respond to, IV quinidine ( Med Lett Drugs Ther 50:37, 2008). To avoid the development of resistance, adults treated with artesunate must also receive oral treatment doses of either atovaquone/proguanil, doxycycline, clindamycin, or mefloquine; children should take either atovaquone/proguanil, clindamycin, or mefloquine (Nosten F, et al: Lancet 356:297, 2000; van Vugt M: Clin Infect Dis 35:1498, 2002; Smithuis F, et al: Trans R Soc Trop Med Hyg 98:182, 2004). If artesunate is given IV, oral medication should be started when the patient is able to tolerate it (SEAQUAMAT group, Lancet 366:717, 2005; Duffy PE, Sibley CH: Lancet 366:1908, 2005). Reduced susceptibility to artesunate characterized by slow parasitic clearance has been reported in Cambodia (Rogers WO, et al: Malar J 8:10, 2009; Dundorp AM, et al: N Engl J Med 361:455, 2009).

75 No drug regimen guarantees protection against malaria. If fever develops within a year (particularly within the first 2 mo) 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 ( Med Lett 45:41, 2003). Malaria in pregnancy is particularly serious for both mother and fetus; therefore, prophylaxis is indicated if exposure cannot be avoided.

76 In pregnancy, chloroquine prophylaxis has been used extensively and safely.

77 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 30 mg base/day or, for children, 0.6 mg base/kg/day during the last 2 wk 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 footnote 69 .

78 Beginning 1-2 wk before travel and continuing weekly for the duration of stay and for 4 wk after leaving malarious zone. Most adverse events occur within 3 doses. Some Medical Letter consultants favor starting mefloquine 3 wk prior to travel and monitoring the patient for adverse events; this allows time to change to an alternative regimen if mefloquine is not tolerated. Mefloquine should not be taken on an empty stomach; it should be taken with at least 8 oz of water. For pediatric doses less than 1/2 tablet, it is advisable to have a pharmacist crush the tablet, estimate doses by weighing, and package them in gelatin capsules. There are no data for use in children weighing < 5 kg, but based on dosages in other weight groups, a dose of 5 mg/kg can be used.

79 Beginning 1-2 days before travel and continuing for the duration of stay and for 1 wk after leaving. In one study of malaria prophylaxis, atovaquone/proguanil was better tolerated than mefloquine in nonimmune travelers (Overbosch D, et al: Clin Infect Dis 33:1015, 2001).

80 Beginning 1-2 days before travel and continuing for the duration of stay and for 1 wk after leaving malarious zone. In one study of malaria prophylaxis, atovaquone/proguanil was better tolerated than mefloquine in nonimmune travelers (Overbosch D, et al: Clin Infect Dis 33:1015, 2001). The protective efficacy of Malarone against P. vivax is variable, ranging from 84% in Indonesian New Guinea (Ling J, et al: Clin Infect Dis 35:825, 2002) to 100% in Colombia (Soto J, et al: Am J Trop Med Hyg 75:430, 2006). Some Medical Letter consultants prefer alternate drugs if traveling to areas where P. vivax predominates.

81 Mefloquine has not been approved for use during pregnancy. However, it has been reported to be safe for prophylactic use during the second or third trimester of pregnancy and possibly during early pregnancy, as well. Mefloquine is not recommended for patients with cardiac conduction abnormalities, and patients with a history of depression, seizures, psychosis, or psychiatric disorders should avoid mefloquine prophylaxis. Resistance to mefloquine has been reported in some areas, such as the Thailand-Myanmar and Thailand-Cambodia borders; in these areas, atovaquone/proguanil or doxycycline should be used for prophylaxis.

82 Beginning 1-2 days before travel and continuing for the duration of stay and for 4 wk after leaving. Use of tetracyclines is contraindicated in pregnancy and in children younger than 8 yr old. Doxycycline can cause GI disturbances, vaginal moniliasis, and photosensitivity reactions.

83 Studies have shown that daily primaquine beginning 1 day before departure and continued until 3-7 days after leaving the malaria area provides effective prophylaxis against chloroquine-resistant P. falciparum (Baird JK, et al: Clin Infect Dis 37:1659, 2003). Some studies have shown less efficacy against P. vivax. Nausea and abdominal pain can be diminished by taking with food.

84 A traveler can be given a course of atovaquone/proguanil, mefloquine, or quinine plus doxycycline for presumptive self-treatment of febrile illness. The drug given for self-treatment should be different from that used for prophylaxis. This approach should be used only in very rare circumstances when a traveler cannot promptly get to medical care.

85 For HIV-infected patients, continue until resolution of ocular symptoms and until CD4 count > 200 cells/µL for > 6 mo after initiation of antiretroviral therapy.

86 Ocular lesions caused by E. hellem in HIV-infected patients have responded to fumagillin eyedrops prepared from Fumidil-B (bicyclohexyl ammonium fumagillin) used to control a microsporidial disease of honey bees (Diesenhouse MC: Am J Ophthalmol 115:293, 1993), available from Leiter's Park Avenue Pharmacy (San Jose, CA; 1-800-292-6773; www.leiterrx.com ). For lesions caused by V. corneae, topical therapy is generally not effective and keratoplasty may be required (Davis RM, et al: Ophthalmology 97:953, 1990).

87 Oral fumagillin (Sanofi Recherche, Gentilly, France) has been effective in treating E. bieneusi (Molina J-M, et al: N Engl J Med 346:1963, 2002), but it has been associated with thrombocytopenia. HAART may lead to microbiologic and clinical response in HIV-infected patients with microsporidial diarrhea (Benson CA, Kaplan JE, Masur H, et al: Treating opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America, MMWR Recomm Rep 53([RR-15]:1-112, 2004). Octreotide (Sandostatin) has provided symptomatic relief in some patients with large-volume diarrhea.

88 Molina J-M, et al: J Infect Dis 171:245, 1995. There is no established treatment for Pleistophora. For disseminated disease caused by Trachipleistophora or Brachiola, itraconazole 400 mg PO once/day plus albendazole may also be tried (Coyle CM, et al: N Engl J Med 351:42, 2004).

89 Albendazole or pyrantel pamoate may be effective (Ziem JB, et al: Ann Trop Med Parasitol 98:385, 2004).

90 Pneumocystis has been reclassified as a fungus. In severe disease with room air P o ₂ ≤ 70 mm Hg or A-aO ₂ gradient ≥ 35 mm Hg, prednisone should also be used (Gagnon S, et al: N Engl J Med 323:1444, 1990; Caumes E, et al: Clin Infect Dis 18:319, 1994).

91 Primary/secondary prophylaxis in patients with HIV can be discontinued after the CD4 count increases to > 200 × 10 ⁶ /L for longer than 3 mo.

92 An alternative trimethoprim-sulfamethoxazole regimen is 1 DS tablet 3×/wk. Weekly therapy with sulfadoxine 500 mg/pyrimethamine 25 mg/leucovorin 25 mg was effective for Pneumocystis carinii pneumonia (PCP) prophylaxis in liver transplant patients (Torre-Cisneros J, et al: Clin Infect Dis 29:771, 1999).

93 Plus leucovorin 25 mg with each dose of pyrimethamine.

94 In some cases, treatment may need to be repeated in 10-14 days (Currie BJ, McCarthy JS: N Engl J Med 362:717, 2010). A second ivermectin dose taken 2 wk later increased the cure rate to 95%, which is equivalent to that of 5% permethrin (Usha V, et al: J Am Acad Dermatol 42:236, 2000). Ivermectin, either alone or in combination with a topical scabicide, is the drug of choice for crusted scabies in immunocompromised patients (del Giudice P: Curr Opin Infect Dis 15:123, 2004).

95 Lindane (γ-benzene hexachloride; Kwell) should be reserved as a second-line agent. The FDA has recommended it should not be used for immunocompromised patients, young children, the elderly, and patients who weigh < 50 kg.

96 Ivermectin, either alone or in combination with a topical scabicide, is the drug of choice for crusted scabies in immunocompromised patients (del Giudice P: Curr Opin Infect Dis 15:123, 2004). The safety of oral ivermectin in pregnancy and young children has not been established.

97 Oxamniquine has been effective in some areas in which praziquantel is less effective (Stelma FF, et al: J Infect Dis 176:304, 1997). Oxamniquine is contraindicated in pregnancy.

98 In East Africa, the dose should be increased to 30 mg/kg, and in Egypt and South Africa to 30 mg/kg/day × 2 days. Some experts recommend 40-60 mg/kg over 2-3 days in all of Africa (Shekhar KC: Drugs 42:379, 1991).

99 In immunocompromised patients or disseminated disease, it may be necessary to prolong or repeat therapy or to use other agents. Veterinary parenteral and enema formulations of ivermectin have been used in severely ill patients unable to take oral medications (Chiodini PL, et al: Lancet 355:43, 2000; Orem J, et al: Clin Infect Dis 37:152, 2003; Tarr PE: Am J Trop Med Hyg 68:453, 2003).

100 Albendazole must be taken with food; a fatty meal increases oral bioavailability.

101 Niclosamide must be thoroughly chewed or crushed and swallowed with a small amount of water. Nitazoxanide may be an alternative (Ortiz JJ, et al: Trans R Soc Trop Med Hyg 96:193, 2002; Chero JC, et al: Trans R Soc Trop Med Hyg 101:203, 2007; Diaz E, et al: Am J Trop Med Hyg 68:384, 2003).

102 Optimal treatment depends on multiple factors, including size, location, and number of cysts and presence of complications. In some patients, medical therapy alone is preferred, but some patients may benefit from surgical resection or percutaneous drainage of cysts. Praziquantel is useful preoperatively or in case of spillage of cyst contents during surgery. Percutaneous aspiration-injection-reaspiration (PAIR) with ultrasound guidance plus albendazole therapy has been effective for management of hepatic hydatid cyst disease (Smego RA Jr, et al: Clin Infect Dis 37:1073, 2003).

103 Surgical excision is the only reliable means of cure. Reports have suggested that in nonresectable cases, the use of albendazole or mebendazole can stabilize and sometimes cure infection (Craig P: Curr Opin Infect Dis 16:437, 2003). Medical treatment is prolonged up to 2 yr or more.

104 Initial therapy for patients with inflamed parenchymal cysticercosis should focus on symptomatic treatment with antiseizure medication. Treatment of parenchymal cysticerci with albendazole or praziquantel is controversial (Maguire JM: N Engl J Med 350:215, 2004). Patients with live parenchymal cysts who have seizures should be treated with albendazole together with steroids (6 mg dexamethasone or 40-60 mg prednisone daily) and an antiseizure medication (Garcia HH, et al: N Engl J Med 350:249, 2004). Some recent studies have shown improved outcomes with combination albendazole and praziquantel (Garcia HH, et al: Lancet Infect Dis 14:687, 2014). Patients with subarachnoid cysts or giant cysts in the fissures should be treated for at least 30 days (Proaño JV, et al: N Engl J Med 345:879, 2001). Surgical intervention or CSF diversion is indicated for obstructive hydrocephalus; prednisone 40 mg/day may be given with surgery. Arachnoiditis, vasculitis, or cerebral edema is treated with prednisone 60 mg/day or dexamethasone 4-6 mg/day together with albendazole or praziquantel (White Jr AC: Annu Rev Med 51:187, 2000). Any cysticercocidal drug may cause irreparable damage when used to treat ocular or spinal cysts, even when corticosteroids are used. An ophthalmic exam should always precede treatment to rule out intraocular cysts.

105 In ocular toxoplasmosis with macular involvement, corticosteroids are recommended in addition to antiparasitic therapy for an antiinflammatory effect.

106 To treat CNS toxoplasmosis in HIV-infected patients, some clinicians have used pyrimethamine 50-100 mg/day (after a loading dose of 200 mg) with sulfadiazine and, when sulfonamide sensitivity developed, have given clindamycin 1.8-2.4 g/day in divided doses instead of the sulfonamide. Atovaquone plus pyrimethamine appears to be an effective alternative in sulfa-intolerant patients (Chirgwin K, et al: Clin Infect Dis 34:1243, 2002). Treatment is followed by chronic suppression with lower-dosage regimens of the same drugs. For primary prophylaxis in HIV patients with < 100 × 10 ⁶ /L CD4 cells, either trimethoprim-sulfamethoxazole, pyrimethamine with dapsone, or atovaquone with or without pyrimethamine can be used. Primary or secondary prophylaxis may be discontinued when the CD4 count increases to > 200 × 10 ⁶ /L for more than 3 mo (Benson CA, Kaplan JE, Masur H, et al: Treating opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America, MMWR Recomm Rep 53([RR-15]:1-112, 2004).

107 Women who develop toxoplasmosis during the first trimester of pregnancy can 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. If transmission has occurred in utero, therapy with pyrimethamine and sulfadiazine should be started (Montoya JG, Liesenfeld O: Lancet 363:1965, 2004). Pyrimethamine is a potential teratogen and should be used only after the first trimester.

108 Plus leucovorin 10-25 mg with each dose of pyrimethamine.

109 Congenitally infected newborns should be treated with pyrimethamine every 2 or 3 days and a sulfonamide daily for about 1 yr (Remington JS, Klein JO, editors: Infectious Disease of the Fetus and Newborn Infant, ed 5, Philadelphia, 2001, WB Saunders, p. 290).

110 Sexual partners should be treated simultaneously. Metronidazole-resistant strains have been reported and can be treated with higher doses of metronidazole (2-4 g/day × 7-14 days) or with tinidazole (Hager WD: Sex Transm Dis 31:343, 2004).

111 Barrett MP, et al: Lancet 362:1469, 2003.

112 The addition of γ-interferon to nifurtimox for 20 days in experimental animals and in a limited number of patients appears to shorten the acute phase of Chagas disease (McCabe RE, et al: J Infect Dis 163:912, 1991).

113 For treatment of T. b. gambiense, pentamidine and suramin have equal efficacy but pentamidine is better tolerated.

114 Eflornithine is highly effective in T. b. gambiense but not against T. b. rhodesiense infections. It is available in limited supply only from the WHO and the CDC. Eflornithine dose may be reduced to 400 mg/kg IV in 2 doses for 7 days when used in conjunction with nifurtimox at a dose of 5 mg/kg PO tid × 10 days (Priotto G, et al: Lancet 374:56, 2009).

115 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 (Pepin J, et al: Trans R Soc Trop Med Hyg 89:92, 1995). Up to 20% of patients with T. b. gambiense fail to respond to melarsoprol (Barrett MP: Lancet 353:1113, 1999). Consultation with experts at the CDC is recommended.

116 Optimum duration of therapy is not known; some consultants would treat for 20 days. For severe symptoms or eye involvement, corticosteroids can be used in addition.

Selected Antiparasitic Drugs for Protozoans

Nitazoxanide (Alinia)

Nitazoxanide is a nitrothiazole benzamide, initially developed as a veterinary anthelmintic. Nitazoxanide inhibits pyruvate-ferredoxin oxidoreductase, which is an enzyme necessary for anaerobic energy metabolism. In humans, nitazoxanide is effective against many protozoans and helminths. Nitazoxanide is approved for the treatment of diarrhea caused by Cryptosporidium parvum and Giardia intestinalis in patients 1 yr of age and older.

Nitazoxanide is available as a tablet and an oral suspension (100 mg/5 mL), which has a pink color and strawberry flavor. The bioavailability of the suspension is ~ 70% compared with the tablet. The drug is well absorbed from the gastrointestinal tract but should be taken with food due to approximately two-fold higher absorption. One third is excreted in urine, and two thirds is excreted in feces as the active metabolite, tizoxanide. Although in vitro metabolism studies have not demonstrated cytochrome P450 enzyme effects, no pharmacokinetic studies have been performed yet in patients with compromised renal or hepatic function. In addition, no studies have been performed in pregnant or lactating women. Common adverse effects include abdominal pain, diarrhea, nausea, and urine discoloration. Rare side effects include anorexia, flatulence, increased appetite, fever, pruritus, and dizziness. Intriguingly, nitazoxanide has in vitro activity against multiple other pathogens, including influenza virus, rotavirus, and hepatitis C virus, although the clinical use of the agent against these viruses remains investigational.

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Selected Antiparasitic Drugs for Protozoans

Nitazoxanide (Alinia)

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