1178

THE NEW ENGLAND JOURNAL OF MEDICINE

May 2, 1996

REVIEW ARTICLE
mebendazole, and albendazole. By binding to free b-tubulin, benzimidazoles inhibit the polymerization of tubulin and the microtubule-dependent uptake of glucose.5 Although resistance to benzimidazole due to a loss of the drug’s high affinity for binding to tubulin6 develops in intensively treated livestock, resistance has not yet been a problem in humans. The newest benzimidazole, albendazole, has a broad range of activity against many nematode and cestode parasites. In the United States, it is available only on a compassionate-use basis from the manufacturer, SmithKline Beecham. The side effects of albendazole (Table 2) usually do not require discontinuation of the drug.7 Its teratogenicity has not been extensively studied, but all benzimidazoles should be avoided, if possible, in women of childbearing age.
Echinococcosis

DRUG THERAPY ALASTAIR J. J. WOOD, M.D., Editor

ANTIPARASITIC DRUGS LEO X. LIU, M.D., D.T.M.H., AND P ETER F. W ELLER , M.D. NFECTIONS with parasitic helminths and protozoa are important causes of morbidity and mortality worldwide. Chemotherapy has an important role not only in the treatment of individual patients but also, in conjunction with public health and vector-control measures, in reducing the transmission of parasitic infections. At present, however, there are no vaccines for human parasitic infections, the scientific knowledge necessary to develop antiparasitic drugs is rudimentary, and the mechanisms of action of most antiparasitic drugs are poorly understood. Commercial incentives for the production of drugs designed to fight infections that are mainly endemic in developing countries are limited, and some proved antiparasitic drugs remain unavailable in the United States. New drugs that are effective against certain parasitic infections have been developed in recent years; in this review we focus our attention on these medications, as well as older drugs that have recently been established to be effective against specific parasites (Table 1). Older, established antiparasitic drugs1-3 and antimalarial drugs4 are not considered here. ANTHELMINTIC DRUGS Parasitic helminths, such as nematodes (roundworms), cestodes (e.g., tapeworms), and trematodes (flukes), are complex multicellular organisms with differentiated nervous systems and organs. In contrast to viruses, bacteria, and protozoa, most helminths do not directly replicate in the human body but reproduce sexually, giving rise to eggs or larvae that pass out of the body. Anthelmintic drugs often affect some of the more complex systems of cellular physiology, such as microtubule formation or neuromuscular function. The emergence of drug resistance in helminths has been much more gradual and limited than in rapidly replicating protozoa, such as the malarial parasite Plasmodium falciparum.
Albendazole

I

The benzimidazole drugs available for the treatment of parasitic diseases in humans include thiabendazole,
From the Department of Medicine, Harvard Medical School, and the Infectious Diseases Division, Beth Israel Hospital — both in Boston. Address reprint requests to Dr. Weller at Beth Israel Hospital, DA-617, 330 Brookline Ave., Boston, MA 02215. 1996, Massachusetts Medical Society.

Albendazole has expanded the therapeutic options for patients with cystic hydatid disease due to Echinococcus granulosus.7 Surgery remains the definitive treatment for this disease, but it carries the risks of operative morbidity, recurrence of cysts, and spillage of fluid from the cysts, which can lead to anaphylaxis or dissemination of the infection. Albendazole reduces the viability of protoscolices and cysts, and its hepatic metabolite, albendazole sulfoxide, is also active against the larval cestodes. The administration of albendazole before surgery has been advocated in order to inactivate protoscolices and minimize the likelihood of recurring cysts.8 Drug therapy is also indicated after the spontaneous or operative rupture of cysts, and the spillage of their contents, to prevent secondary dissemination.9 The usual four-week course of treatment (Table 2) often needs to be repeated two or more times. The absorption of albendazole is enhanced by taking it with fatty meals.10 Albendazole is indicated for patients with inoperable, widespread, or numerous cysts of E. granulosus and for patients with complicated medical problems who are unsuitable candidates for surgery.7,11 Percutaneous drainage has also been successfully used to treat hepatic hydatid cysts, and when combined with albendazole therapy, further reduces the size of cysts.12,13 Albendazole is also useful as adjunctive medical therapy for alveolar hydatid disease due to E. multilocularis14,15 and may be effective against infection with E. vogeli.16 In infection with either E. granulosus or E. multilocularis, however, the response to albendazole occurs only after many months. Furthermore, in most treated patients the cystic lesions do not resolve completely, although they cease to enlarge.11 Thus, when feasible, surgical excision of echinococcal cysts remains the definitive therapy, and albendazole should be administered in conjunction with surgery or to patients who are not candidates for surgery.
Intestinal Tapeworms and Cysticercosis

Infection with intestinal tapeworms can be treated effectively with available anthelmintic drugs, including

Downloaded from www.nejm.org on April 25, 2004. This article is being provided free of charge for use in Argentina: NEJM Sponsored. Copyright © 1996 Massachusetts Medical Society. All rights reserved.

Copyright © 1996 Massachusetts Medical Society. pseudospiralis38 and Oesophagostomum bifurcum. For patients with Schistosomiasis Praziquantel. 18 DRUG THERAPY 1179 Table 1. onchocerciasis and loiasis. This article is being provided free of charge for use in Argentina: NEJM Sponsored. pyrantel pamoate* Albendazole* therapeutic use of praziquantel. or intraocular cysts. tissue infection with the larval PARASITE AND INFECTION STANDARD TREATMENT POTENTIAL NEW TREATMENT stage of Taenia solium (cysticercosis).35 clonorchiasis. oxamniquine (for Schistosoma mansoni) inactive disease and calcified tissue Fascioliasis Bithionol* Triclabendazole* cysts.nejm. with viable intraparenchyIntestinal tapeworms Praziquantel* mal cysts (which can be seen as lowCysticercosis Surgery. Single doses of ticerci.30 although 22 in one study. but not praziquantel.2 However.29 Neither drug in a single dose is highatively long half-life of albendazole might allow for ly effective in eradicating Trichuris trichiura. Albendazole is not active are endemic. three doses of albendazole resulted in an twice-a-day dosing for this condition. Helminths and especially neurocysticercosis. but it may be effective 23 Albendazole has also proved effective or promising even in patients with solitary cysts and seizures alone. have contributed to continuing uncertainty about the precise indicaostomiasis. against a number of less common nematode infections Clinical variability and a tendency toward spontaneous of tissue. including cutaneous larva migrans. acute meningitis.17.37 as well tions for anthelmintic therapy — and even its overall as more recently recognized infections with Trichinella usefulness — in this disease.* ivermectin* Tissue nematodes more recently of albendazole.31 with numerous viable cysts. Medical therapy is definitely indicated for patients 80 percent rate of cure. . intestinal flukes Cestodes however.17. cysts in 80 to 90 percent of patients. pyrantel pamoate Albendazole.39 Alben25 has proved effective. Chemotherapy for Parasitic Diseases. praziquantel and niclosamide.* ivermectin* Enterobiasis Mebendazole. however. Plasma concentrations of albendazole.* ivermectin* nable only to surgical therapy. and Praziquantel* needed. specific cesticidal therapy is not Other liver. hookfilarial nematodes.27. on occasion.32. praziquantel. albendazole.21 Pharmacokinetic studies suggest that the relworm infections.40 but not as efnal. All rights reserved. lung.26 whom thiabendazole — despite its frequent side efIntestinal Roundworms fects41 — remains the drug of choice. Cyclosporiasis Trimethoprim–sulfamethoxazole* The administration of either praIsosporiasis Trimethoprim–sulfamethoxazole* Cryptosporidiosis Supportive fluid and electrolyte Paromomycin* ziquantel or albendazole results in therapy the reduction or disappearance of *Not approved by the Food and Drug Administration for this indication. are higher in patients treated with cortiboth albendazole (Table 2) and mebendazole are highcosteroids. than praziquantel in reducing the number and size of Such mass treatment has been advocated as a compocysts and in inducing overall clinical improvement. †AIDS denotes acquired immunodeficiency syndrome. 2004.24 For patients with giant subarachnoid cysts.* albendazole* Echinococcosis Surgery Albendazole* density cysts on computed tomography with little or no enhancement Protozoa Giardiasis Metronidazole* Albendazole* with contrast medium) requires drug Microsporidiosis in AIDS† None Albendazole.34 intestinal capillariasis. was for a long time ameTrichuriasis Mebendazole Albendazole. and Strongyloidiasis Thiabendazole Albendazole. and trichuriasis — are among the most zole has a limited ability to reduce the number of miprevalent infections in the world. for has obviated the need for surgery. 334 No.43 possibly because of an embryotoxic effect on the adult worms.org on April 25. Active neurocysticercosis. pyrantel pamoate Albendazole. treatment with albendazole the hyperinfection syndrome of strongyloidiasis. the efficacy of single doses of albendazole Downloaded from www. In areas in which they crofilariae. The effectiveness py.20 A shorter course of albendazole (8 days) ly effective against ascariasis. For patients with ventricular.28 These two drugs have also been used exten17 sively in individually tailored therapy. although concurrent therapy with albendazole is adof albendazole has not been evaluated in patients with visable and. the Intestinal nematodes most prevalent helminthic infection Ascariasis Mebendazole.33 gnathresolution in neurocysticercosis. surgery is the preferred therafective as ivermectin (see next page). has Onchocerciasis Ivermectin provided medical treatment for neuTrematodes 17 rocysticercosis. In infections with Soil-transmitted helminthiases — ascariasis.42.* fumagillin* treatment. The Hookworm infection Mebendazole. spidazole (400 mg twice daily for three days) is moderately effective for chronic strongyloidiasis. In comparative trials albendazole (5 mg per kilogram of body weight or the older benzimidazole drug mebendazole has made three times daily for 28 to 30 days) was more effective mass chemotherapy feasible for school-age children.Vol. or inOther Roundworms creased intracranial pressure. albendaworm infection.29 although albendazole appears to be as effective as the traditional 28-to-30-day appears to be more effective than mebendazole in hookcourse.36 and infection with lagochilascariasis minor.17-19 Adjunctive therapy with dexamethasone is recommendnent of control measures to reduce the number of worms ed for patients with numerous cysts and for those in in individual children below pathogenic levels and has whom neurologic symptoms or intracranial hypertenimproved children’s growth and academic performsion develops after the initiation of therapy against cysance. but not praziquantel. ivermectin of the brain.

ivermectin is effective against M.nejm. 2004. with amelioration of pruritus Strongyloidiasis (uncomplicated)* 400 mg twice daily for 3 days but no resolution of depigmentation. ozzardi55 but not M.* trichuriasis* 12 mg once punctate keratitis and iritis are diStrongyloidiasis* 200 mg/kg once daily for 1–2 days Paromomycin Abdominal discomfort minished. dizziness. repeated in 2 weeks duced. nitis. but it does not kill Nanophyetus salmincola* 20 mg/kg three times daily for 1 day adult worms. the reduction in microfilaremia is not sustained. mass chemotherapy with iverLiver (Clonorchis sinensis. haematobium 20 mg/kg twice daily for 1 day discomfort By decreasing the number of miS. repeated as necessary mal and ocular microfilariae. rash.46 Onchocerciasis Other Filariases A single oral dose of ivermectin (150 mg per kilogram) greatly reduces the number of microfilariae in The effectiveness of ivermectin in onchocerciasis has led to field trials of the drug for cases of lymphatic filariasis. All rights reserved. mansoni. even Trichuriasis* 400 mg once (repeated for 3 days in severe onchocercal dermatitis is reheavy infections) Enterobiasis* 400 mg once. but because it Downloaded from www. and — in rare cases — ocular †AIDS denotes acquired immunodeficiency syndrome.org on April 25. revomiting.50 Schistosomiasis drowsiness. In areas where the disAlbendazole Abdominal pain. 25 mg/kg three times daily for 1 day impair the fertility of female onHeterophyes heterophyes.49. japonicum. Metagonimus yokogawai)* chocerca worms. perstans. . Fish. limbs. alopecia. In the United States.45 It appears to kill helminths by opening chloride-sensitive channels.51 Table 2. inflammation. there are no effects Cryptosporidiosis* 500 mg three to four times daily for 2 weeks on sclerosing keratitis or chorioretiPraziquantel Headache. Ivermectin Ivermectin is an extremely potent. S. and fewer microfilariae are Giardiasis (during pregnancy) 8–10 mg/kg three times daily for released in the anterior chamber and 7 days cornea. broad-spectrum. dizziOcular disease also responds: damOnchocerciasis* 150 mg/kg once ness age to the optic nerve is lessened. Newer Uses of Antiparasitic Drugs. Copyright © 1996 Massachusetts Medical Society.47 thus diminishing the likelihood of disabling onDRUG AND INDICATION DOSAGE ADVERSE EFFECTS chocerciasis.45 In humans. anthelmintic drug that has been widely used in controlling nematode infections in animals. beef. inrepeated every 6 to 12 months to peated as necessary creased serum aminomaintain suppression of both derNeurocysticercosis* 5 mg/kg three times daily for 8–30 transferase.1180 THE NEW ENGLAND JOURNAL OF MEDICINE May 2.47 AfAscariasis. neutropenia days. but it is not active against adult filarial worms in the lymphatic system. ivermectin leads to clearance of the microfilariae of Wuchereria bancrofti and Brugia malayi from the blood.* hookworm infection* 400 mg once ter therapy with ivermectin. and a single dose of diethylcarbamazine appears to be as well tolerated and effective as ivermectin in inducing a sustained reduction in microfilaremia.52 However. A well-tolerated drug Neurocysticercosis* 15–20 mg/kg three times daily for 15 days that is effective against adult onIntestinal tapeworm infection chocerca worms has yet to be found. Ascariasis. mansoni infection 15 mg/kg once. to the Onchocerciasis Control Program of the World Bank and the World Health Organization. S. 30 mg/kg in East Afsis (Table 2) are mainly due to host rica. 30 mg/kg for 2 days in Egypt reactions to the dying microfilariae and South Africa Fumagillin and include pruritus. ivermectin decreases microfilaremia. through supplies donated by the manufacturer.54 With respect to other filarial parasites. edema of the face and *Not approved by the Food and Drug Administration for this indication.47 These side effects are usually mild and less severe than with diethylcarbamazine. papular rash. 1996 the skin and eyes. However. mekongi 20 mg/kg three times daily for 1 day crofilariae in the skin of infected perFluke infection sons.48 Microsporidiosis in AIDS*† 400 mg twice daily for 2–3 weeks Ivermectin Mild pruritus. 25 mg/kg three times daily for 1 day Opisthorcis viverrini)* mectin reduces transmission of this Lung (paragonimus)* 25 mg/kg three times daily for 2 days vector-borne disease. No adverse effects have been in infections with the filarial parasite Mansonella perobserved in women inadvertently treated during pregstans. the other major filarial infection. abdominal S.51-54 A single dose of ivermectin is as effective as the traditional 14-day course of diethylcarbamazine in lowering the number of circulating microfilariae and has far fewer side effects. Microsporidial keratoconjunctivitis* Eye drops dizziness. This article is being provided free of charge for use in Argentina: NEJM Sponsored. Ivermectin may Intestine (Fasciolopsis buski. In single doses of between 100 and 440 mg per kilogram. Merck. ivermectin is available on a compassionate-use basis from Merck. and dog* 5–10 mg/kg once The side effects of ivermectin therDwarf (Hymenolepsis nana)* 25 mg/kg once Oxamniquine apy for patients with onchocerciaS. nausea. and in the free-living nematode Caenorhabditis elegans the drug binds to a glutamate-gated chloride channel. ease is endemic. the dose can be Echinococcosis* 400 mg twice daily for 28 days.44 nancy. it has been used most extensively against onchocerciasis (river blindness). Ivermectin is a semisynthetic macrocyclic lactone derived from avermectins of the soil mold Streptomyces avermitilis. pork.56 In Loa loa infections.

the flagellates.60. In some areas of endemic schistosomiasis the low rates of cure attributable to praziquantel might be due to extremely rapid reinfection rather than any intrinsic drug resist- Albendazole.58. and enterobius. as seen in a few promising studies. which responds to bithionol (given at a daily dose of 30 to 50 mg per kilogram on alternate days for 10 to 15 doses)2 and. is highly effective against chronic intestinal strongyloidiasis. praziquantel causes antigens within the parasite to be exposed to the action of host antibodies.57 Other Roundworms ance of the parasite. as compared with a rate of 38 percent with albendazole. The only fluke not responsive to praziquantel is Fasciola hepatica (sheep-liver fluke).75 ANTIPROTOZOAL DRUGS Protozoan parasites belong to four distinct groups: the amebae. a longer course of praziquantel is effective for neurocysticercosis (Table 2).59 Ivermectin. given as a single oral dose) cured 83 percent of patients with the disease.2.2 Treatment of intestinal Taen.58 It is ineffective against hookworms in humans. increases the peak serum concentration of praziquantel and lengthens the drug’s elimination half-life. the ciliates.68 In addition.63-65 Praziquantel For infection with intestinal tapeworms.61 Ivermectin has also proved effective for strongyloidiasis in patients with the acquired immunodeficiency syndrome (AIDS). in a daily dose of 200 mg per kilogram for one or two days. to the veterinary drug triclabendazole. Other Flukes Ivermectin is also effective against several common intestinal parasitic nematodes.73 Phenytoin and carbamazepine induce metabolism of praziquantel by hepatic cytochrome P-450 and have contributed to treatment failures. and quinacrine (no longer distributed in the United States). This article is being provided free of charge for use in Argentina: NEJM Sponsored. caused by the flagellated protozoan Giardia lamblia (also known as G.58 for which mebendazole is the treatment of choice.74 Cimetidine. 2004. praziquantel (Table 2) in a single dose is effective. this limitation of metabolism is exacerbated by dexamethasone and the antiepileptic drugs that are often given concomitantly with praziquantel for seizure control in patients with neurocysticercosis. we review some of those for which new. In areas where schistosomiasis is endemic. including scabies and head lice.62 A series of doses of ivermectin may be effective in the hyperinfection syndrome of strongyloidiasis. A single 12-mg dose of ivermectin was more effective than a single 400-mg dose of albendazole for cutaneous larva migrans in one study. Albendazole Giardiasis Praziquantel is an effective drug against a broad range of trematode and cestode infections. solium infections can lead to neurologic reactions in patients who have occult neurocysticercosis.72 The bioavailability of praziquantel is limited by extensive first-pass metabolism of the drug. For infection with Schistosoma mansoni. Giardiasis is currently treated with metronidazole (although the drug is not approved for this indication by the Food and Drug Administration). Giardiasis. and the sporozoa. Of the many diseases due to protozoan parasites. Although the drug has been in clinical use for over a decade.nejm. including ascaris. snail-transmitted parasites that cause the disease. a pathogen of the small bowel. but experience with its use in disseminated strongyloidiasis is limited. All rights reserved. trichuris. Schistosomiasis Praziquantel is the drug of choice for all forms of schistosomiasis (Table 2). as noted above. often rapidly.67 Perhaps by disrupting the surface membrane of the parasite. mass treatment with praziquantel has been used as a means of control of the waterborne.67 Studies of parasitic schistosomes indicate that the immune response of the host and the formation of specific antibodies are necessary to create praziquantel’s anthelmintic effects. this property makes it potentially useful in the treatment of some protozoan infections in addition to its more established roles in therapy for helminthic infections. binds to tubulin and affects cytoskeletal microtubules. Ectoparasites Praziquantel is also effective in the treatment of most flukes (Table 2).70 although patients with neurocysticercosis often have no response to a single dose of praziquantel. as well as in other countries.71 As noted above. is one of the most common diarrheal infections in the United States. Side effects of treating strongyloidiasis with ivermectin are less frequent than with thiabendazole. 18 DRUG THERAPY 1181 is not clearly effective against adult worms — the stage of the parasite primarily responsible for human symptoms — diethylcarbamazine remains the drug of choice. albendazole inhibits the growth of trophozoites of G. in the infected host. lamblia and their adhesion Downloaded from www.61 a difficult infection to eradicate.org on April 25. although albendazole may be more efficacious. they are all single-cell organisms and replicate.60 In one study of strongyloidiasis. drugs hold promise as treatment. treatment with praziquantel has enhanced patients’ physical fitness. duodenalis). 334 No.Vol. oxamniquine (Table 2) is an effective and cheaper alternative to praziquantel. its mode of action is still not clearly understood.66 Praziquantel appears to interfere with calcium homeostasis and causes flaccid paralysis in adult flukes. Unlike helminths.66 and the drug was ineffective in a few large-scale campaigns. resistance to the drug has been found in infected mice.2 In vitro. tinidazole (not available in the United States). or older. However. ivermectin (150 to 200 mg per kilogram.69 Cestodes Ivermectin may be effective in treating ectoparasites in humans. Copyright © 1996 Massachusetts Medical Society. which inhibits hepaticenzyme metabolism. .

and nosema — and some other unclassified microsporidia cause human disease. All rights reserved. pyrimethamine alone (75 mg per day. In both an open trial 98 and a small double-blind trial 99 of paromomycin (in a dose of 500 mg three or four times a day for two weeks) in patients with AIDS who had cryptosporidiosis. with less frequent stools and often decreased fecal excretion of microsporidial spores. treatment with a combination of 160 mg of trimethoprim and 800 mg of sulfamethoxazole (i.99 Paromomycin given orally is not systemically absorbed. Copyright © 1996 Massachusetts Medical Society. septata. for those intolerant of sulfa drugs. 1996 to cultured intestinal epithelial cells and disrupts the activity of microtubules and microribbons in the trophozoite’s adhesive disk.96 Alternatively. Symptomatic cyclosporiasis may recur in the following weeks.org on April 25. Over four decades ago. Several recent studies suggest that an older oral aminoglycoside. treatment with one double-strength tablet of trimethoprim–sulfamethoxazole four times a day for 10 days leads to a rapid resolution of diarrhea.77 Five genera of microsporidia — enterocytozoon. although a water-soluble form of the drug. a newly recognized coccidian protozoan parasite. fumagillin was found to inhibit the activity of intestinal protozoa.82-86 After the cessation of albendazole therapy.97 Paromomycin Cryptosporidiosis Fumagillin is a water-insoluble antibiotic produced by Aspergillus fumigatus. or disseminated disease in patients with AIDS.nejm. This article is being provided free of charge for use in Argentina: NEJM Sponsored.88-90 Maintenance therapy with twice-daily topical administration of fumagillin was necessary to prevent symptomatic relapses. . An effective antiparasitic drug for cryptosporidiosis in patients with AIDS is greatly needed. and continued treatment with 500 mg twice daily is needed to prevent relapse. until the infection is cleared) is effective and can be followed with a maintenance dose of 25 mg per day to prevent relapses. Cryptosporidiosis is usually a self-limited enteric infection in immunocompetent patients but a potentially debilitating and chronic diarrheal illness in patients with AIDS or other immunocompromised states. even in patients with intestinal cryptosporidiosis. Currently. had symptomatic improvement with albendazole. pleistophora. is used to control microsporidial disease due to Nosema apis in honeybees.93 In patients infected with the human immunodeficiency virus.91 causes diarrheal illness. however. Fumagillin Ocular Microsporidiosis tients. paromomycin is used as a secondary drug in therapy for amebiasis2 and in pregnant women in whom giardiasis is not severe enough to require therapy with metronidazole. but many drugs have proved ineffective. may be at least partially effective in treating cryptosporidiosis. it suppresses the proliferation of microsporidia in vitro. so longer-term suppressive treatment may be needed. but it can be prevented by the administration of trimethoprim–sulfamethoxazole three times weekly.87 Fumagillin had not been used in human infections.76 but it was ineffective in a study of adult travelers returning from tropical areas. fumagillin bicyclohexylammonium salt. cured 97 percent of infections in children in Bangladesh.1182 THE NEW ENGLAND JOURNAL OF MEDICINE May 2. the causative agent of amebiasis. principally with Enterocytozoon bieneusi and Septata intestinalis. 2004.33 Microsporidiosis Unlike giardiasis. in whom recurrences are common. Microsporidia are small. ocular. in doses of 400 mg per day for five days. spore-forming obligate intracellular protozoan parasites that only rarely infect immunocompetent patients but that may cause intestinal. in the United States and other countries. Trimethoprim– sulfamethoxazole. In patients with AIDS. patients with AIDS who had intestinal microsporidial infections. by no means a new antimicrobial preparation. for which there are effective drugs. Although the mechanism of action of fumagillin has not been established. Albendazole disrupts the function of tubulin in microsporidia78 and has antimicrosporidial activity both in vitro and in vivo.88 Trimethoprim–Sulfamethoxazole Cyclosporiasis Cyclospora.. the drug reduced diarrhea. Albendazole.79-81 Although current clinical trials of albendazole in microsporidiosis have not been completed. is efficacious in treating diarrheal disease caused by cyclospora.98 CONCLUSIONS A variety of infections with protozoan and helminthic parasites are prominent worldwide health prob- Downloaded from www.92-94 In immunocompetent pa- Cryptosporidium parvum is a common cause of diarrhea in ungulate farm animals and a major cause of waterborne outbreaks of diarrhea among humans. longterm maintenance therapy with double-strength trimethoprim–sulfamethoxazole tablets given three times a week or a combination of 25 mg of pyrimethamine and 500 mg of sulfadoxine given once a week can be effective. encephalitozoon. symptomatic illness often recurred.e. often prolonged. The results of treatment of giardiasis with albendazole have been mixed. cuniculi in several patients with AIDS. in the double-blind study the fecal excretion of cryptosporidiosis oocysts was also reduced.81 A topical suspension of fumagillin was effective in the treatment of microsporidial keratoconjunctivitis due to Encephalitozoon hellem or Enceph.100 It is not likely to be a definitive antiparasitic therapy.95 The double-strength tablet is given orally four times a day for 10 days and then twice a day for 3 weeks. paromomycin.94 Isosporiasis Trimethoprim–sulfamethoxazole is also effective in treating enteric infections with Isospora belli. a double-strength tablet) twice daily for seven days ended diarrheal illness and led to clearance of the parasites. including Entamoeba histolytica. the various forms of microsporidiosis have until recently proved difficult to treat.

12. A controlled trial of ivermectin and diethylcarbamazine in lymphatic filariasis. Grantham-McGregor SM. Jones BR. Copyright © 1996 Massachusetts Medical Society. Bundy DA. Cross JH.44:154-9.45:445-74. Ottesen EA.35:565-74.237:69-72.88:585-9. Cloning of an avermectin-sensitive glutamate-gated chloride channel from Caenorhabditis elegans. Q J Med 1993. . Kinoti SN. Alpers M. J Neurol 1990. 2004. Ambu S. 42.49:2904. Diagnosis and treatment of human hydatidosis. Dexamethasone increases plasma levels of albendazole.88:110-2. Am J Trop Med Hyg 1992. Magro JE. Alawi KS. Munoz B. Cooper ES. 36. Gill GV. Gil-Grande LA. Treatment of subperiodic Brugia malayi infection with a single dose of ivermectin. Greene BM.18:507-10.104:27-31. Southeast Asian J Trop Med Public Health 1993.85:244-7. Basaca-Sevilla V.156:662-5. Clinical pharmacokinetics of albendazole in patients with brain cysticercosis. Gao P. Treatment of strongyloidiasis with thiabendazole: an analysis of toxicity and effectiveness. Proc R Soc Lond B Biol Sci 1992. Percutaneous drainage versus albendazole therapy in hepatic hydatidosis: a prospective. Aguirre R. Kazura J.Vol. J Infect Dis 1991. Experimental and clinical trial of albendazole in the treatment of Clonorchiasis sinensis.327:696-701. 6. 31. Wyler DJ. Trans R Soc Trop Med Hyg 1982. Ottesen EA. et al. Doyer M. Rausch RL. Am J Trop Med Hyg 1993. Kraivichian P. Therapy for neurocysticercosis: a reappraisal. 14. Del Brutto OH. Therapy for neurocysticercosis: comparison between albendazole and praziquantel.129:588-91. 49:535-8. Malaria chemoprophylaxis for the traveler. Hauser WA.19:735-42. Albendazole in the treatment of intestinal capillariasis. Kulkumthorn M. 27. Medina MT. levamisole and thiabendazole. Albendazole in human loiasis: results of a double-blind. Abiose A. Jung H. Hepatology 1994.104:1452-9. 50. Wen H. Lancet 1993. 53. 32. Arch Dermatol 1993. Trans R Soc Trop Med Hyg 1994. Greenberg J. Carpio A. Drugs for parasitic infections. Bellucci AD. 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