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Chemotherapy of Intestinal Parasites in Southeast Asia

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Chemotherapy of Intestinal Parasites in Southeast Asia CHEMOTHERAPY OF INTESTINAL PARASITES IN SOUTHEAST ASIA DANAI BUNNAG and TRANAKCHIT HARINASUTA Department of Clinical Tropical Medicine and Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. INTRODUCTION mgjday for five days. In another study Levi et al., (1977) used metronidazole and tinida­ The common intestinal parasites in the zole for 7 days and obtained cure rates of 80% Southeast Asian countries are as follows: and 97% respectively. The side effects were mild gastrointestinal disturbances. Protozoa: Giardia Iamblia Amoebiasis Entamoeba histolytica Asymptomatic amoebiasis or cyst passers is Helminths: commonly encountered, but the prevalences Hookworm varied widely. The prevalent rate in children Ascaris lumbricoides in Indonesia were 21% in West Flores and Enterobius vermicularis 31% on Alor Island (Partono and Soewata, Trichuris trichiura 1980; Carney et al., 1974), whereas the Strongyloides stercolaris prevalence on children in a Bangkok; Or­ Capillaria philippinensis phanage was 18%, in school children from provincial towns of Chumporn and Nakhon Taenia saginata, Taenia solium Nayoki, Thailand were 0.8% and 0.6% Fasciolopsis buski respectively (Chongsuphajaisiddhi et al., Opisthorchis viverrini 1978). Other intestinal flukes. Dichloroacetamide derivatives are sparingly The treatment of these parasitoses are absorbed from the intestines. These are white variable. or yellowish powders, insoluble in water and tasteless. Four compounds are in use but only Giardiasis diloxamide furoate is effective; 500 mg three Giardiasis is most common in children times daily for 10 days gave a high cure rate especially in orphanages and other institu­ of 96% (Woodruff and Bell, 1960). The mode tions·, and is manifested by recurrent episodes of action is not known. of watery or bulky motions and diarrhoea. Symptomatic intestinal amoebiasis is re­ An effective drug has been mepacrine, 100 mg latively mild and very few cases of fulminating three times daily for five days yielded a 100% amoebic dysentery with the passage of cure, but the drug is no longer marketed. intestinal casts are encountered. Dichloroace­ Nittoimidazole derivatives are also effective; tamide and nitroimidazole derivatives are tinidazole, metronidazole and o~nidazole in commonly used. The former group includes: a Single dose of 2 gm gave cure rates of 86 %, 52% and 96 %, respectively (Sabcharoen Clefamide N-(B-oxyethy 1)-N-(p-phenoxy-) et al., 1980) while Kavousi (1979) obtained a 4-nitro)-benzyl) dichloroaceta­ 100% response using metronidazole 15-25 mide (250 mg tab) 422 Vol. 12 No. 3 September 1981 CHEMOTHERAPY OF INTESTINAL pARASITES Etofamide closely related to clefamide Prophylactic treatment of intestinal amoe­ (200 mg tab) biasis is often practised using dichloroaceta­ mide derivatives, the efficacy of which has not Teclozan dichloroacetyl-ethyl- amino­ been evaluated. ethyl-benzene, (100 mg tab) Amoebic liver abscess is the most common The nitroimidazole derivatives are com­ form of extraintestinal amoebiasis. In Thai­ pletely absorbed from the intestines and kill land we have recorded about 1,000 cases the trophozoites; the amoebic cyst however during the past 30 years and has been routinely resists these compounds at low dose, (Chong­ treated this condition with tissue amoebicides suphajaisiddhi, 1971). Metronidazole has and aspiration of pus. During the last 14 been used since 1959 for Trichomonas vagina­ years metronidazole was used with varying lis and in 1965-1966 it was prescribed for dosages and for the last 10 years tinidazole amoebiasis. Side effects occur in 20-30% has been used in the Hospital for Tropical and include metallic taste, upper gastroin­ Diseases. So far, there has been no relapses testinal symptoms. The nervous system is less or treatment failures. frequently affected, producing headache, dizziness and numbness oflimbs. The dosage Metronidazole 400 mg three times daily used in symptomatic amoebiasis is 600 mg for 10 day yielded a 100% cure with 6 months three times daily for 5-10 days. follow up (Harinasuta et al., 1975). Tinidazole has similar properties to metro­ Tinidazole 800 mg three times a day for 5 nidazole but the blood level at 24 hour after days yielded the same result in 8 patients administration was higher (Sawyer et al., (Bunnag and Harinasuta, 1973). A single 1976). It is excreted unchanged. Disulfiram­ day dose of 2.4 gm and 1.2 gm were studied like reactions with alcohol are observed as in in 12 and 5 patients respectively, obtaining metronidazole and are characterised by excellent results (Bunnag and Harinasuta, confusion, flushing, headache, drowsiness, 1974). Since then a single dose of 1.2 gm nausea, vomiting and hypotension. The has been given to 34 patients, the clinical optimal dosage is 2 gm daily for 2-3 days response and the healing of the abscess cavity which is a shorter course than that of metroni­ have been satisfactory. Occasional~y very dazole. large abscesses, with a diameter of 15 em and over are encountered, then 2.4 gm dose Ornidazole is similar to tinidazole and for five days was used. A patient with an metronidazole and the manufacture claims a abscess of 31 em vertical diameter was high plasma concentration in 1-2 hours, no sucessfully treated with 2.4 gm daily for five incompatibility with alcohol, little neurotoxi­ days and 28 aspirations of 5.53 litres of city, no teratogenicity and no carcinogenicity. pus. It has been recommended in symptomatic intestinal amoebiasis at 500 mg twice daily Occasionally amoebic liver abscess is for 5-10 days (Gruneberg et a!., 1970; complicated with Escherichia coli infection Schweitzer, 1976). and a dose or two of aminoglycoside diluted with 20 ml of distilled water is introduced Emetine and dehydroemetine hydrochlo­ into the cavity after aspiration. The aspirates ride are less frequently used nowadays. from subsequent attempts are cultured to Tetracycline 1 gm daily for 10 days in monitor the presence of bacteria. Aspiration symptomatic amoebiasis yielded a high cure should be performed daily or on alternate rate of 97% (Powell et a!., 1965). days until the pus is sterile or when there Vol. 12 No. 3 September 1981 423 SouTHEAST AsiAN J. TRoP. MilD. Pus. HLTH. is no faecal odour. Systemic antibiotics are each year of life for a maximum number recommended in severely ill patients. of 25 fruits (Harinasuta, 1962). The fruits are pounded and the juice collected by strain­ The cavity of an abscess in the liver can be ing and 15-30 ml of lime water or coconut visualised roentgenologically by injection of milk added. The cure rate was 30-80% radio opaque medium (5 ml of 40% iodised (Migasena et a!., 1974; Unhanand et al., oil) and 50-100 ml of air; P.A and lateral 1978). About one million people was treated films are then takien. By measurement of the in mass campaign against intestinal parasites vertical and horizontal and anteroposterior in 1977-1979, however optic atrophy was diameters, the size of the cavity is estimated reported in 8 patients who had taken the (Harinasuta and Harinasuta, 1966). juice kept over-night (Limpaphayom et al., The study of the rate of healing was carried 1977). This might be due to the oxidative out by taking X-rays at intervals (both P-A process during storage and some had taken and lateral films). When the cavity was an over dose. The substance could be toxic obliterated, the oil was seen as collection of to the retina and optic nerve. droplets. If there was recrudescence i.e. Pyrantel pamoate, a tetrahydropyrimidine the cavity being formed again, the opaque is a crystalline powder, insoluble in water medium would spread and line the bottom of the cavity. A medium size abscess cavity and slightly absorbed. It inhibits neuromuscu­ (7.0-8.0 em in diameter) in our series took lar transmission producing spastic paralysis about 4-6 weeks to heal (Harinasuta and of the worms. The drug is given at 10-20 Bunnag, 1970). mg/kgjday for two-three consecutive days with cure rate of 63 %-83 %. The side effects The healing process of amoebic liver are mild and transient including nausea, abscess was also studied in 125 patients. vomiting, diarrhoea and abdominal cramps It was noted that the abscess cavity healed from the central towards the peripheral (Bhaibulaya et al., 1975; Migasena et a!., part of the liver (Harinasuta and Bunnag, 1978). 1970). Mebendazole, a benzimidazole derivative, Surgical drainage should be avoided as is a white, yellowish powder, very slightly secondary infection is very common and soluble in water and tasteless. It inhibits leakage of pus into the pleural cavity is often the glucose uptake leading to glycogen unavoidable; antibiotics are needed in large depletion and death of the worms. When amount for these patients. the drug is used at 100 mg twice daily for three days, it yielded a 90% cure rate. Hookworm infection The side effects are mild and transient (Bunnag et al., 1976; Migasena et al., 1978). Severe hookworm disease is not common however hookworm infection is a common Flubendazole, is a paraflouro analoque of soil-transmitted helminthic infection in mebendazole and when given in two doses of Southeast Asia. Various drugs have been 300 mg at 24 hour intervals yielded a 81% used. Ma-klua (Diospyros mollis), fruits from cure rate by egg count method, the mean an indigenous plant used to dye cloth black percentage of egg reduction was 96. The side has been used in treatment of human hook­ effects weee mild and transient. It has the worm (Sadun and Vajrasthira, 1954). The same efficacy as mebendazole (Bunnag dose is calculated by age, one fruit for eta/., 1980c). 424 Vol. 12 No. 3 September 1981 CHEMOTHERAPY OF INTESTINAL pARASITES Tetrachloroethylene given at 0.1 ml per kg, considerable choice of anthelminthics in the the maximum dose of 4-5 ml in gelatine treatment of pinworm infection.
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