TABLE 4.
Suggested antimicrobial therapy for infections with various blood- and tissue-associated protozoaa
| Organism | Suggested antimicrobial therapyc |
|---|---|
| Microsporidia | Effective HAART leading to immune restoration can result in clinical cure of microsporidiosis; restoration of CD4+ cell counts of >100 cells/μl should lead to clinical improvement; for treatment of disseminated infections with Encephalitozoon hellem, Encephalitozoon cuniculi, or Encephalitozoon intestinalis, albendazole (400 mg orally twice daily for 3 weeks) can be used; there is no established treatment for Pleistophora or Anncaliia species infections, although albendazole therapy as described above is recommended; for disseminated infections with Trachipleistophora, albendazole (400 mg oral twice daily for 3 weeks) plus itraconazole (400 mg oral daily for 3 weeks) are recommended; clindamycin has also demonstrated some anti-E. intestinalis activity (300 mg orally every 6 h)b; treatment for ocular infections with E. hellem, E. cuniculi, Vittaforma corneae, or Nosema ocularum includes fumigillin (Fumidil B) at 3 mg/ml in saline (final concn of 70 μg/ml fumigillin) in eye drop form plus albendazole (400 mg orally twice daily for 3 weeks) |
| New World CL and MCL (Mexico, Central America, South America) | Always begin treatment of MCL with antimonial therapy; recommended primary therapy of sodium stibogluconate or meglumine antimoniate (20 mg/kg of body wt/day i.v. for 28 days); in Brazil, antimony and pentoxifylline (400 mg orally 3 times a day for 30 days) are superior to antimonial treatment alone; alternatives are amphotericin B (1 mg/kg i.v. every other day for 20 doses), liposomal amphotericin B (3 mg/kg/day i.v. for 6 days [3 weeks for MCL]), or miltefosine (2.5 mg/kg/day orally for 28 days); oral miltefosine is effective against L. panamensis, marginal against L. mexicana, and ineffective against L. braziliensis |
| Old World CL and MCL (Europe, Asia, and Africa) | Stibogluconate or meglumine antimoniate (20 mg/kg/day i.v. for 10 days) |
| Visceral leishmaniasis | Recommended primary therapy of liposomal amphotericin B (3 mg/kg/day i.v. for 5 days followed by 3 mg/kg on days 14 and 21); alternatives are liposomal amphotericin B (10 mg/kg/day i.v. for 2 days), stibogluconate or meglumine antimoniate (20 mg/kg/day i.v. in a single dose for 28 days), miltefosine (1.5-2.5 mg/kg/day orally for 28 days), or standard amphotericin B (1 mg/kg i.v. every other day for 20 days) |
| Trypanosoma cruzi | For adults, nifurtimox (8-10 mg/kg/day orally [after meals] divided into 4 doses for 120 days); for children 11-16 yr of age, nifurtimox (12.5-15 mg/kg/day orally [after meals] divided into 4 doses for 90 days); for children <11 yr of age, nifurtimox (15-20 mg/kg/day orally [after meals] divided into 4 doses each day for 90 days); an alternative is benznidazole (5-7 mg/kg/day orally divided into 2 doses each day for 30-90 days) |
| Trypanosoma brucei gambiense sleeping sickness (lymphatic stage) | Recommended therapy is pentamidine (4 mg/kg/day i.m. for 10 days); an alternative is suramin (100-mg i.v. test dose followed by 1 g i.v. on days 1, 3, 7, 14, and 21) |
| Trypanosoma brucei gambiense sleeping sickness (late CNS stage) | Recommended therapy is melarsoprol (2.2 mg/kg/day i.v. for 10 days); an alternative is eflornithine (100 mg/kg i.v. every 6 h for 14 days) |
| Trypanosoma brucei rhodesiense sleeping sickness (lymphatic stage) | Suramin (100-mg i.v. test dose followed by 1 g i.v. on days 1, 3, 7, 14, and 21) |
| Trypanosoma brucei rhodesiense sleeping sickness (late CNS stage) | Melarsoprol (2-3.6 mg/kg/day i.v. for 3 days, repeat after 7 days, and repeat for a third time 7 days after the second course) |
| Toxoplasma gondii | Treatment is often complex, depending on immune status and the presence or absence of pregnancy; no recommended treatment for immunologically healthy individuals unless there is evidence of severe symptoms or organ damage; treatment of congenital toxoplasmosis is also very complex; for acute infection in pregnancy at <18 wks of gestation, spiramycin (1 g every 8 h orally until delivery) can be used if amniotic fluid is PCR negative; for acute infection in pregnancy at >18 wks of gestation and if amniotic fluid is PCR positive, pyrimethamine (50 mg every 12 h orally for 2 days and then 50 mg/day orally) plus sulfadiazine (75 mg/kg orally for 1 dose and then 50 mg/kg every 12 h orally) plus leucovorin (10-20 mg/day orally) can be used; in cases of chorioretinitis, meningitis, or lowered resistance due to cytotoxic drugs or steroids in non-AIDS patients, pyrimethamine (200 mg/day orally for 1 dose and then 50-75 mg every 24 h) plus sulfadiazine (1-1.5 mg orally 4 times daily) plus leucovorin (5-20 mg orally 3 times per week) can be used (continue for 2 weeks after symptoms subside), and also add prednisone (1 mg/kg/day i.v. in 2 divided doses to reduce CSF protein or vision-threatening inflammation) |
| AIDS-related cerebral toxoplasmosis | For prevention of cerebral toxoplasmosis in AIDS patients (prophylaxis), trimethoprim-sulfamethoxazole DSe (1 tablet orally every 24 h) or trimethoprim-sulfamethoxazole SSf (1 tablet orally every 24 h); alternatives are dapsone (50 mg orally every 24 h) plus pyrimethamine (50 mg orally per week) plus leucovorin (10-25 mg orally every 24 h) or atovaquone (1,500 mg orally every 24 h); recommended therapy for cerebral toxoplasmosis is pyrimethamine (200 mg orally for 1 dose) followed by pyrimethamine (75 mg/day orally) plus sulfadiazine (1-1.5 g orally every 6 h) plus oral leucovorin (10-20 mg daily) continued for 4-6 weeks after resolution of symptoms or trimethoprim-sulfamethoxazole (10-50 mg/kg/day orally or i.v. divided into 12 hourly doses) for 30 days; alternatives for use in patients with sulfa intolerance are pyrimethamine (200 mg/kg orally for 1 dose) followed by pyrimethamine (75 mg/kg/day orally) plus leucovorin (10-20 mg orally daily) plus one of either (i) clindamycin (600 mg orally or i.v. every 6 h), (ii) clarithromycin (1 g orally twice daily), (iii) azithromycin (1.2-1.5 g orally every 24 h), or (iv) atovaquone (750 mg orally every 6 h), with treatment for 4-6 weeks after resolution of symptoms; for suppression after resolution of cerebral toxoplasmosis, sulfadiazine (500-1,000 mg orally 4 times daily) plus pyrimethamine (25-50 mg orally every 24 h) plus leucovorin (10-25 mg orally every 24 h) (discontinue if CD4+ cell count is >200 for at least 3 mo), clindamycin (300-450 mg orally every 6-8 h) plus pyrimethamine (25-50 mg orally every 24 h) plus leucovorin (10-25 mg orally every 24 h), or atovaquone (750 mg orally every 6-12 h) is recommended |
| Babesia spp. | Recommended therapy is atovaquone (750 mg orally twice a day for 7-10 days) plus azithromycin (500 mg orally for 1 dose and then 250 mg every 24 h for 7 days); an alternative is clindamycin (600 mg orally 3 times a day) plus quinine (650 mg orally 3 times a day for 7-10 days); adults can receive i.v. clindamycin (1.2 g twice daily); immunocompromised patients should be treated for more than 6 wk |
| Free-living amoebae | For these organisms no proven treatment regimens exist; these treatment options are based on successful regimens described in case reports |
| Acanthamoeba spp. | Treatment is a 3-mo course of oral cotrimoxazole plus oral rifampin, a lipid formulation of i.v. amphotericin B plus oral voriconazole, high-dose i.v. amphotericin B plus oral 5-fluorocytosine, or oral trimethoprim-sulfamethoxazole plus oral rifampin plus oral ketoconazole; for treatment of cutaneous lesions, topical chlorhexidine and 2% ketoconazole cream and oral itraconazole are used; for treatment of Acanthamoeba keratitis, propamidine (0.1%) and neomycin-gramicidin-polymyxin eye drops, PHMB (0.02%) eye drops, or chlorhexidine (0.02%) eye drops are used |
| Balamuthia mandrillaris | Pentamidine (300 mg i.v. once a day), sulfadiazine (1.5 g orally 4 times daily), fluconazole (400 mg orally daily), and clarithromycin (500 mg orally 3 times daily) or fluconazole (400 mg oral daily), sulfadiazine (1.5g orally every 6 h), clarithromycin (500 mg orally 3 times daily) |
| Naegleria fowleri | Intrathecal amphotericin B (1.5 mg/kg/day in 2 divided doses for 3 days); this is followed by intrathecal amphotericin B (1 mg/kg/day for 6 days), followed by intrathecal amphotericin B (1.5 mg/day for 2 days) and then intrathecal amphotericin B (1 mg/day every other day for 8 days) |
| Sappinia pedata | Azithromycin, pentamidine, itraconazole, and flucytosine therapyd |