Parasitology treatment – aide-memoire

Acanthamoeba

Keratitis:
Polyhexanide (PHMB) 0.02%
Chlorhexidine 0.02% (+/- Brolene 0.1%)
Propamidine (0.1%) or
hexamidine (0.1%)
Imidazole, neomycin,
NSAID, prednisolone.
(Ref: Acanthamoeba Keratitis Treatment, AAO; Focus, Autumn 2013, RCOphth)
Granulomatous amoebic encephalitis:
The optimum treatment is unknown. A combination of drugs has been used – cotrimoxazole, metronidazole, pentamidine, miltefosine, and fluconazole.
Other drugs with activity – Azithromycin, rifampicin, voriconazole, flucytosine, caspofungin etc.
Cutaneous lesion:
Optimum treatment is unknown. Drugs used-
Topical chlorhexidine, ketoconazole cream,
Pentamidine, Itraconazole, voriconazole, liposomal amphotericin B, flucytosine, miltefosine etc

Balamuthia

Granulomatous amoebic encephalitis:
Optimum treatment is unknown. various combinations of
Pentamidine, miltefosine,
Flucytosine, liposomal amphotericin B, fluconazole, itraconazole
cotrimoxazole, sulfadiazine,
Azithromycin, clarithromycin has been used.

Naegleria

Primary amoebic meningoencephalitis:
Optimum treatment is unknown.
Combination of Amphotericin B, fluconazole, rifampicin, miltefosine, Azithromycin has been reported. [Linan] [Sharma][Grace]
Steroid.

Microsporidia

Gastrointestinal:
Albendazole (except E. bieneusi, see Galván),
Fumagilin (?availability)
Metronidazole, voriconazole, doxycycline, nitazoxanide, quinolone, azithromycin, furazolidone etc has been tried.
Ocular microsporidial keratoconjunctivitis:
Albendazole, Fumagilin eye drops, topical fluoroquinolone, topical voriconazole.

Immune reconstitution.

Entamoeba histolytica

Acute invasive amoebic dysentery/ Amoebic abscess:
Metronidazole/ tinidazole.
Chronic infections or following metronidazole or tinidazole:
Diloxanide furoate.

Trichomonas vaginalis

Metronidazole/ Tinidazole .
Paromomycin,
Furazolidone,
Acetarsol, 6% Nonoxynol–9. (BASHH).

Giardia

Metronidazole,
Tinidazole, Mepacrine hydrochloride.

Leishmania

Sodium stibogluconate,
liposomal amphotericin,
Pentamidine isetionate,
Meglumine antimoniate +/- Pentoxifylline
Paromomycin,
Fluconazole, Ketoconazole,
Miltefosine.

Trypanosoma brucei (African trypanosomiasis)

Trypanosoma brucei gambiense:
Early – Pentamidine/ Suramine
Late – Melarsoprol/ Eflornithine +/- Nifurtimox
Trypanosoma brucei rhodesiense:
Early – Suramine,
Late – Melarsoprol.

Trypanosoma cruzi (Chagas disease)

Benznidazole, Nifurtimox.

Cyclospora

Cotrimoxazole,
Nitazoxanide, Ciprofloxacin.

Isospora

Cotrimoxazole
Ciprofloxacin, Nitazoxanide

Cryptosporidium

Nitazoxanide, Paromomycin.
Usually, self-limiting in immunocompetent.

Toxoplasma

Pyrimethamine and Sulfadiazine,
Pyrimethamine and Clindamycin/Clarithromycin/Azithromycin,
Spiramycin
Cotrimoxazole, Atovaquone.

Babesia

Quinine + Clindamycin
Azithromycin+Atovaquone

Malaria

Uncomplicated P. falciparum
Artemether–lumefantrine (DoC),
Dihydroartemisinin-piperaquine,
Quinine +/- Doxycycline,
Atovaquone–proguanil.
Severe falciparum malaria, or infections complicated by a relatively high parasite count:
Intravenous artesunate (DoC),
Intravenous quinine
Non-falciparum malaria
Artemether–lumefantrine or
Dihydroartemisinin-piperaquine
Chloroquine
P. vivax or P. ovale hypnozoites:
Primaquine
Pregnancy
1st trimester – quinine and clindamycin
2/3 trimester – artemether–lumefantrine
Non-falciparum – Chloroquine
Postpone Primaquine until the pregnancy is over.
[Ref: UK malaria treatment guidelines 2016, BNF]

Enterobius vermicularis (Threadworm/pinworm)

Mebendazole (DoC)
Other drugs – Albendazole, Pyrantel pamoate, Ivermectin.

Hygienic measures (see NICE CKS)

Trichuris trichiura (Whipworm)

Mebendazole
Other drugs – Albendazole (+/- Ivermectin), Pyrantel/Oxantel pamoate.

Ascaris

Mebendazole (DoC)
Levamisole

Albendazole
Ivermectin
Pyrantel

Hookworm (Ankylostoma, Necator)

Mebendazole,
Albendazole
Pyrantel pamoate.

Larva migrans (Dog and Cat hookworm – Ancylostoma caninum and Ancylostoma braziliense)

Ivermectin, Albendazole

Strongyloides

Ivermectin (DoC), Albendazole.

Trichinella

Albendazole, Mebendazole

Corticosteroid

Loa loa

Diethylcarbamazine (DEC) – DoC
Albendazole

Onchocerca volvulus (river blindness)

(Loa loa coinfection needs to be ruled out before treatment – to avoid fatal encephalitic reaction to ivermectin)
Ivermectin, Moxidectin

Doxycycline (kills the bacteria Wolbachia on which the adult worms depends for its survival).

Taenia saginata

Praziquantel,
Niclosamide.

Taenia solium

Praziquantel,
Niclosamide.
CNS disease (neurocysticercosis)
Corticosteroid, stabilisation of intracranial pressure (if high)
Albendazole +/- Praziquantel

Diphylobothrium (fish tapeworm)

Praziquantel,
Niclosamide.

Hymenolepis nana (dwarf tapeworm), H diminuta (rat tapeworm)

Praziquantel,
Nitazoxanide, Niclosamide

Echinococcus (Hydatid)

Surgical resection with a scolicidal agent (hypertonic saline/ethanol ).
Percutaneous management – PAIR technique (puncture, aspiration, injection, reaspiration) – using scolicidal agent.
Albendazole, Mebendazole

Schistosomiasis

Acute schistosomiasis syndrome/Katayama fever:
Steroid, Praziquantel.
Chronic infection:
Praziquantel.

Clonorchis sinensis (oriental live fluke)

Praziquantel,
Albendazole, Mebendazole.

Fasciola hepatica (Liver fluke)

Triclabendazole,
Nitazoxanide,
Bithionol.

Fasciolopsis buski (Intestinal fluke)

Praziquantel

Heterophysiasis

Praziquantel

Paragonimiasis

Triclabendazole,
Praziquantel,
Bithionol.

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