Table 5.

Commonly used drug combinations and treatment alternatives for human babesiosis with regard to parasite species and severity of the disease (adapted and modified from Hildebrandt et al., 2013 [111]).

Parasite	Mild Disease a (Drug)	Severe Disease a,b (Drug)	Adjunctive/Alternative Therapy in Severe Cases b
B. divergens	clindamycin	clindamycin plus quinine	Exchange transfusion, hemodialysis consider atovaquone/azithromycin, atovaquone/proguanil or pentamidine/ trimethoprim-sulfametoxazole as possible alternatives for severe and intractable infections
B. venatorum	clindamycin	clindamycin plus quinine	Exchange transfusion, Consider alternative treatment with atovaquone/azithromycin or atovaquone/proguanil in persisting babesiosis
B. microti	atovaquone plus azithromycin	clindamycin plus quinine	Exchange transfusion hemodialysis Consider adding doxycycline or proguanil in relapsing or persisting babesiosis

^a Usual duration of treatment is 7–10 days. Longer treatment (>6 weeks) may be necessary in immunocompromised or relapsed patients. In immunocompromised individuals, reduction of immunosuppressive therapy may be needed if possible for clearing the parasite. ^b Severe illness criteria according to White et al., 1998 [113]: parasitemia > 4%, alkaline phosphatase >125 U/L and white blood cell counts >5 × 10⁹/L. Partial or complete exchange transfusion is recommended in case of high parasitemia (>10%), severe anemia (<10 g/dL) and pulmonary or hepatic failure. In severe disease cases i.v. treatment is suggested. Alternative treatments as derived from single case reports or case studies cited in the literature (Hildebrandt et al., 2013 [111]).