Table 3.

Suggested Treatments for Adult Patients with Human Granulocytic Anaplasmosis or Babesiosis in the United States

Disease	Antibiotics	Grade	Alternative Option	Gradeg
Human Granulocytic Anaplasmosis
	Doxycycline 100 mg orally or intravenously twice daily for 10 days	I-B	Rifampin 300 mg orally twice daily for 10 days	IIb-C
Babesiosis
Mild	Azithromycin 500 mg orally on day 1 and 250 mg orally once daily from day 2 to day 7-10 plus Atovaquone 750 mg orally twice daily from day 1 to day 7-10	I-B
Severe	Clindamycin 300-600 mg intravenously four times daily plus Quinine 650mg orally three to four times daily for 7-10 days Consider exchange transfusion	I-Ca,b,c IIa-Ca	Azithromycin 500 mg intravenously once daily plus Atovaquone 750 mg orally twice daily for 7-10 days Consider exchange transfusion	IIb-Ca,d IIa-Ca
			Clindamycin 300-600 mg intravenously four times daily plus Atovaquone 750 mg orally twice daily for 7-10 days Consider exchange transfusion	IIb-Ca,b,c,e IIa-Ca
In highly immuno-compromised patients	Drug regimen(s) administered for at least 6 weeks, including 2 weeks with no parasites on blood smear. See text for the various drug regimens.	I-Bf

^arecommended for the treatment of severe babesiosis in hospitalized patients.

^bquinidine may be used in lieu of quinine (when poorly tolerated or intravenous administration is desired) or atovaquone (when intravenous administration is desired), although efficacy data are scarce¹³⁴. Quinidine requires cardiac monitoring due to the risk of QT interval prolongation and torsade de pointes¹³⁵.

^cintravenous clindamycin may be replaced with oral clindamycin 600 mg administered three times per day once the patient has improved.

^dthis regimen was not included in the 2006 IDSA guidelines² but should be considered when intravenous administration is desired. Intravenous azithromycin may be replaced with oral azithromycin 500 mg per day once the patient has improved. Atovaquone should not be replaced with intravenous quinidine because patients receiving both azithromycin and quinidine may be at increased risk of cardiac arrhythmias^135,136.

^ethis regimen was not included in the 2006 IDSA guidelines², but has been used successfully in several cases^59,91,92.

^fwhen treating highly immunocompromised patients, higher doses of azithromycin (600-1000 mg per day orally) should be considered^2,99.

^gsee Supplemental Table 1 for AHA evidenced based scoring system