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Appendix I. Therapeutic Recommendations (Reprinted from the Medical Letter) the Medical Letter® on Drugs and Therapeutics

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Appendix I. Therapeutic Recommendations (Reprinted from the Medical Letter) the Medical Letter® on Drugs and Therapeutics Appendix I. Therapeutic Recommendations (Reprinted from The Medical Letter) The Medical Letter® On Drugs and Therapeutics Published by The Medical Letter, Inc .• 1000 Main Street, New Rochelle, NY. 10801 • A Nonprofit Publication Vol. 35 (Issue 911) December 10, 1993 DRUGS FOR PARASITIC INFECTIONS Parasitic infections are found throughout the world. With increasing travel, immigration, use of immunosuppressive drugs, and the spread of AIDS, physicians anywhere may see infections caused by previously unfamiliar parasites. The table below lists first-choice and alternative drugs for most parasitic infections. Adverse effects of antiparasitic drugs are listed on page 120. For information on the safety of antiparasitic drugs in pregnancy, see The Medical Letter Handbook of Antimicrobial Therapy, 1992, page 151. DRUGS FOR TREATMENT OF PARASITIC INFECTIONS Infection Drug Adult Dosage* Pediatric Dosage* AMEBIASIS (Entamoeba histolytica) a.ymptomatlc Drug of choice: lodoquinol' 650 mg tid x 20d 30-40 mg/kg/d in 3 doses x 20d OR Paromomycin 25-30 mg/kg/d in 3 doses x 7d 25-30 mg/kg/d in 3 doses x 7d Alternative: Diloxanide furoate' 500 mg tid x 10d 20 mg/kg/d in 3 doses x 10d mild to mod.rat. Int•• tlnal dl••••• Drugs of choice:3 Metronidazole 750 mg tid x 10d 35-50 mg/kg/d in 3 doses x 10d OR Tinidazole' 2 grams/d x 3d 50 mg/kg (max. 2 grams) qd x 3d s.v.r. Int•• tlnal dis.as. Drugs of choice:3 Metronidazole 750 mg tid x 10d 35-50 mg/kg/d in 3 doses x 10d OR Tinidazole' 600 mg bid x 5d 50 mg/kg (max. 2 grams) qd x 3d Alternative: Dehydroemetine' 1 to 1.5 mg/kg/d (max. 90 mg/d) 1 to 1.5 mg/kg/d (max. 90 mg/d) 1M in 2 1M for up to 5d doses for up to 5d h.patlc .b.c••• Drugs of choice:3 Metronidazole 750 mg tid x 10d 35-50 mg/kg/d in 3 doses x 10d OR Tinidazole' 800 mg tid x 5d 60 mg/kg (max. 2 grams) qd x 3d Alternatives: Dehydroemetine' 1 to 1.5 mg/kg/d (max. 90 mg/d) 1 to 1.5 mg/kg/d (max. 90 mg/d) 1M in 2 1M for up to 5d doses for up to 5d follow.d by chloro­ 600 mg base (1 gram)/d x 2d, 10 mg base/kg (max. 300 mg base)/d quine phosphate then 300 mg base (500 mg)/d x 2-3 wks x 2-3wks AMEBIC MENINGOENCEPHALITIS, PRIMARY DrugN.·I1'er'. of choice: Amphotericin 85.8 1 mg/kg/d IV, uncertain duration 1 mg/kg/d IV, uncertain duration Acanthamoab. Drug of choice: See footnote 7 * The letter d stands for day. 1. Dosage and duration of administration should not be exceeded because of possibility of causing optic neuritis; maximum dosage is 2 grams/day. 2. In the USA, this drug is available from the CDC Drug Service, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; telephone: 404-1139-3670 (evenings, weekends, end holidays: 404-639-2888). 3. Treatment should be followed by a course of iodoquinol or one of the other intraluminal drugs used to treat asymptomatic amebiasis. 4. A nitro-imidazole similar to metronidazole, but not marketed in the USA; tinidazole appears to be at least as effective as metronidazole and better tolerated. Ornidazole, a similar drug, is also used outside the USA. 5. One patient with a Naaglaria infection was successfully treated with amphotericin 8, miconazole, and rifampin (JS Seidel et ai, N Engl J Med, 306:346, 1982). 6. An approved drug, but considered investigational for this condition by the U.S. Food and Drug Administration EDITOR: Merk Abramowicz. M.D. EDITORIAL BOARD: Martin A. Rinck. M.D .• Ph.D., Consulting Editor, Rockef.ller Univ.; Jul •• Hirsch, M.D .• Rockef.ller Univ.; JIm •• D. Ken· ney. M.D .• Vele UnlV'. School of Med.; Lewll P. Rowlend. M.D., Coli. of PhYI .• Surg. of Columbia Unlv.; Finton SchaWnlr, M.D .• Mt. Sinai School of Med.; N.a' H. Stelgblg.', M.D .• Albert Einstein Call. of Med. ADVISORY BOARD: Martin D. AblloW. M.D., Johns Hopkins Uni"'; William T. ae."er, M.D .• Georgetown Univ. School 0' Med.; Alan J. Gelan­ berg, M.D •• Univ. of Arizonl Health Sciencea Clnter; Louis S. Goodman, M.D .• Univ. of Utah Coli. of Med.; Philip D. Hanstan. Pharm. D.• Univ. of Washington: Gerhard L,vy. Pharm. D.• State Univ. of N.Y. at Buffalo; Gerald L. Mand,n. M.D., Univ. of Virginia School of Mad.; Dan M. Roden, M.D .• Vanderbilt School of Med.; F. Eat,nl R. Simons. M.D .• University of Manitoba; John H. Tinker. M.D .• Univ. of low. Call. of Med. ASSOCIATE EDITOR: Donna Goodatlln; ASSISTANT EDITOR: Am, Faucard PUBLISHER: C. J. 'arllins Founded 1969 by Arthur Kanet and Harold Aaron. M.D. Copyright" ,.13. The Medical Letter. Inc. (lSSN 0025·732X) Reprinted by permission of The Medical Letter, Copyright 1993. 288 Therapeutic Recommendations Infection Drug Adult Dosage· Pediatric Dosage· Ant:y/ostoma duodena". see HOOKWORM ANGIOSTRONGYLIASIS Anlllos"onllylus cantonens/s Drug of choice: Mebendazole'·... 100 rng bid x 5d 100 mg bid x 5d Anlliosuonllylus coster/cens/s Drug of choice: Thiabendazole'" 75 mg/kg/d in 3 doses x 3d (max. 75 mg/kg/d in 3 doses x 3d (max. 3 3 grams/d) '0 grams/d)'o ANISAKIASIS (Anisakis) Treatment of choice: Surgical or endoscopic removal ASCARIASIS (Ascaris lumbricoides. roundworm) Drug of choice: Mebendazole 100 mg bid x 3d 100 mg bid x 3d OR Pyrantel pamoate 11 mg/kg once (max. 1 gram) 11 mg/kg once (max. 1 gram) OR Albendazole 400 mg once 400 mg once BABESIOSIS (Babesia microti) Drugs of choice:" Clindamycin' 1.2 grams bid parenteral or 600 20-40 rng/kg/d in 3 doses x 7d mg tid oral x 7d plus quinine 650 mg tid oral x 7d 25 mg/kg/d in 3 doses x 7d BALANTIDIASIS (Balantidium coli) Drug of choice: Tetracycline· 500 mg qid x 10d 40 mg/kg/d in 4 dosas x 10d (max. 2 grams/d)u Alternatives: 10doquinolU 650 mg tid x 20d 40 mg/kg/d in 3 doses x 20d Metronidazole' 750 mg tid x 5d 35-50 mg/kg/d in 3 doses x 5d BAYLISASCARIASIS (Baylisascaris procyon/s) Drug of choice: See footnote 13 BLASTOCYSTIS hominis infection Drug of choice: See footnote 14 CAPILLARIASIS (Capillaria philippinensis) Drug of choice: Mebendazole8 200 mg bid x 20d 200 mg bid x 20d Alternatives: Albendazole 200 mg bid x 10d 200 mg bid x 10d Thiabendazole· 25 mg/kg/d in 2 doses x 30d 25 mg/kg/d in 2 doses x 30d Ch.Da.· dl•••••• see TRYPANOSOMIASIS Clonorchis .Inens". see FLUKE infection CRYPTOSPORIDIOSIS (Cryptosporidium) Drug of choice: See footnote 15 CUTANEOUS LARVA MIGRANS (creeping eruption. dog and cat hookworm) Drug of choice:'8 Thiabendazole Topically and/or 50 mg/kg/d in 2 Topically and/or 50 mg/k~/d in 2 doses doses (max. 3 grams/d) x 2-5d'0 (max. 3 grams/d) x 2-5d 0 OR Albendazole17 200 mg bid x 3d 200 mg bid x 3d CYCLOSPORA infection 18 Drug of choice: Trimethoprim­ TMP 160 mg. TMP 5 mg/kg. sulfamethoxa­ SMX800 mg SMX 25 mg/kg zole'· bid x 3 days bid x 3 days • The letter d stands for day. 7. Strains of Acanthamoeba isolated from fatal granulomatous amebic encephalitis are usually sensitive in vitro to pentamidine. ketoconazole (NizoralJ. flucytosine. and (less so) to amphotericin B (RJ Duma et al. Antimicrob Agents Chemother. 10:370. 1976). For treatment of keratitis caused by Acanthamoeba. concurrent topical use of 0.1% propamidine isethionate (Bro/ene - RhOne-Poulenc Rorer. Canade) plus neosporin. or oral itraconazole plus topical miconazole. have been successful (MB Moore and JP McCulley. Br J Ophthalmol. 73:271. 1989; V Ishibashi et al. Am J Ophthalmol. 109:121. 1990). Topical polyhex­ amethylene biguanide has also been effective in a few patients with keratitis (JH Varga et al. Am J Ophthalmol. 115:466. 1993). 8. Effectiveness documented only in animals 9. Most patients recover spontaneously without antiparasitic drug therapy. Analgesics. corticosteroids. and careful removal of CSF at frequent intervals can relieve symptoms (J Koo et al. Rev Infect Dis. 10:1155. 1988). Albendazole. levamisole (Ergam­ isol). or ivermectin has also been used successfully in animals. 10. This dosa is likely to be toxic end may have to be decreased. 11. Exchange transfusion has been used in severely ill patients with high (>10%) parasitemia (V lacopino and T Earnhart. Arch In­ tern Med. 150:1527. 1990). One report indicates that azithromycin (Zithromax). 500-1000 mg daily. plus quinine may also be effective (LM Weiss et al. J Infect Dis. 168:1289. 1993). Concurrent use of pentamidine and trimethoprim-sulfamethoxazole has been reported to cura an infection with B. divergens (0 Raoult et al. Ann Intern Med. 107:944. 1987). 12. Not recommended for use in children less than eight years old. 13. Drugs that could be tried include diethylcarbamazine. levamisole. and fenbendazole (KR Kazacos. J Am Vat Med Assoc. 195:894. 1989) and ivermectin. Steroid therapy may be helpful. especially in eye or CNS infection. Ocular baylisascariasis has been treated successfully using laser therapy to destroy intraretinallarvae. 14. Clinical significance of these organisms is controversial. but metronidazole 750 mg tid x 10d or iodoquinol 650 mg tid x 20d anecdotally have been reported to be effective (I Grossman et al. Am J Gastroenterol.
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