Pharmacotherapy of

Parasitic infestations
Teshale A. Mega

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Parasitic infections: classified
1. Protozoan diseases
o Giardiasis, amebiasis,
malaria, and Chagas' disease
2. Helminthic infections
o Ascariasis, enterobiasis,
hookworm, strongyloidiasis,
and cestodiasis
3. Ectoparasitic infestations
o Head and body lice
Giardiasis
• Giardia intestinalis or
Giardia duodenalis
• Most common intestinal
parasite responsible for
diarrheal syndromes
• Susceptible
o Achlorhydria, hypogammaglobulinemia, or
deficiency in secretory IgA
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 Pathophysiology
• Two stages in the life cycle:
o G. lamblia: the trophozoite
and the cyst
 Ingestion of G. lamblia cysts
in contaminated water or food.
 Protozoan excysts release
the trophozoite (low pH).
o Mucosal invasion, localized
edema, and flattening of the villi,
resulting in malabsorption states.

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 Clinical presentation and Dx
o Steatorrhea, lactose intolerance,
 Acute vitamin B12, and fat-soluble
o Diarrhea, cramp-like vitamin deficiencies.
abdominal pain, bloating, and

o
flatulence
Malaise, anorexia, nausea,
Stool examination
and belching.   1. Fresh stool
o Trophozoites
Chronic 2. Preserved specimen
o Diarrhea: foul-smelling, copious, o Cysts
light-colored, fatty stools; weight loss
o Periods of diarrhea alternating
with constipation

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 Pharmacotherapy
 Adults & children >8years Pediatric :
old o Metronidazole15 mg/kg for 5 to 7
o Metronidazole 250 mg po tid/ 5 to days.
10 days. o Furazolidone suspension 6 mg/kg
o Tinidazole 2 gm/day with food qid/7 to 10 days
o Nitazoxanide 500mg po bid with o Nitazoxanide suspension 200 to
food × 3 days. 500 mg bid/3 days
Pregnancy:  Albendazole 400 mg daily for 5
o Paromomycin 25-30 mg/kg days
per day tid/7 days. o Cure rates of 97%

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 Monitoring
 Average parasitological  Metronidazole use in
cure rates at 1 to 4 weeks pregnancy?
o Above 90% for
metronidazole (77%-100%)  Diarrhea: 1 to 2 weeks
o Tinidazole (80%-100%)  Good personal hygiene
o Above 75% for nitazoxanide and caution in food and
(64%-94%). drink consumption.
 Metronidazole failure
o Nitazoxanide: 500 mg
twice daily for 3 days

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 Amebiasis
 E. histolytica vs. E. dispar
 Incidence: 50million cases;
>100,000 deaths
• Susceptible
– Institutionalized mentally retarded
patients, sexually active
homosexuals, patients with AIDS,
new immigrants from developing
countries.
• Fecal-oral route of transmission

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 Clinical presentation and Dx
 Liver abscesses (lungs and
pleura)
 Pericardial infections, erosion
of liver abscesses, peritonitis.
 Lose faeces, abdominal cramp,
bloody stools
Diagnosis
 Fresh stool
o Three stool samples obtained 24
hours apart (60% to 90%)
o Presence of E. histolytica cysts or
trophozoites
 Microscopy of stools
o E. histolytica vs. E. dispar
 ELISA (antigen detection)
 Endoscopy
 Serology and liver scans
o Ultrasound, CT or MRI.
 Leukocytosis (>10,000/mm3)
and an elevated ALP(>75%)
 Needle aspiration
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 Treatment
1. Electrolyte replacement
2. Nutritional support
3. Percutaneous catheter
drainage
4. Surgery
5. Antibiotic therapy

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 Monitoring
• Response: 3 to 5 days 3. Computed
• Liver abscess tomography (CT):
o 7 to 10 days
Liver abscess
 Day #5 and 7, at the
 Repeat
1. Colonoscopy: Colitis end of the course of
2. Stool examination, therapy, and a month
serology after the end of therapy

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 Ascaris lumbricoides (roundworm)
Ascariasis (nematodes)

Poor sanitation area

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 Ascariasis (nematodes)
Clinical manifestations
o Abdominal discomfort,
abdominal obstruction,
vomiting, and
appendicitis
o Pneumonitis, fever,
cough, eosinophilia, and
pulmonary infiltrates.

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 Ascariasis (nematodes)
Diagnosis
• Characteristic egg in the
stool.
Treatment:
• Mebendazole (Vermox®)
100 mg po bid/3 days.
o Quimox 500mg po stat
• Albendazole 400 mg as a
single dose.

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Taenia (cestodes)

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 Taenia (cestodes)
Taenia solium
• Ingestion of poorly cooked meat
that contains the larvae or
cysticercus.
• Cysticercus matures (about 8
weeks) into the adult tapeworm
and attaches to the host
jejunum.
• The larvae can penetrate the bowel
and migrate through the
bloodstream to infect different
organs including the CNS
(neurocysticercosis).
• In the CNS: can produce
hydrocephalus, intracranial
hypertension, stroke, and
seizure.
• Neurocysticercosis:
Epileptic seizures (50% to
80%)
• Subcutaneous nodules,
primarily in the arms, legs,
and chest.
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 Taenia (cestodes) treatment
Neurocysticercosis
o Anthelminthic therapy
o Anticonvulsants
o Surgery
• Anthelminthic therapy:
o Albendazole: 400 mg twice
daily for 15days.
o About 30 days for extensive
disease
o Albendazole 400mg bid
plus 6mg dexamethasone
QD/10 days significantly
decreases generalized
seizures
• Pediatric: 15 mg/kg (max:
800 mg) bid/15days.
• Praziquantel
o A 50 mg/kg/day for 15 days
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 Malaria
 Most devastating disease in
terms of human suffering and
economics.
• About 300-500 million new infections
annually in the world, and between 1
to 2 million deaths.
• The primary reasons for deaths:
1. Failure to take chemoprophylaxis
2. Inappropriate chemoprophylaxis
3. Delay in seeking medical care
4. Misdiagnosis
 The species of malaria parasite
1. P. falciparum and p. malariae
o Remain in the primary
exoerythrocytic stage in the liver
for about 4 weeks before
invading erythrocytes
2. P. vivax and p. ovale
o Can exist in the liver in the latent
exoerythrocytic form for extended
periods, and, infected subjects
can experience relapses
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Etiology and life cycle

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 Pathogenesis and clinical feature
 Features distinguish P. falciparum • The erythrocytic phase
infection from the benign o Extensive hemolysis
malarias o Results in anemia and
1) High level of parasitemia splenomegaly
o Invade erythrocytes of all ages unlike • High risk for severe complications
p.vivax and p.ovale whih target mature RBCs from falciparum malaria
2) Undergo ‘sequestration’ o Infants and children younger than 5
o Mature parasites adhere to endothelial years of age
cells in the post capillary venules of o Non-immune and pregnant women
critical organs such as brain, heart, liver,
kidney • P. malariae
Þ Hence extensive vascular disease and o Immune-mediated glomerulonephritis and
severe metabolic effects nephrotic syndrome

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 Clinical presentation
 Erythrocytic phase
1. Prodrome: headache,
anorexia, malaise, fatigue,
myalgia
– Nonspecific complaints such as
abdominal pain, diarrhea, chest
pain, and arthralgia
2. Paroxysm: high fever, chills,
and rigor
3. Cold phase: severe pallor
and cyanosis of the lips
4. Hot phase: fever between
40.5°C and 41°C
5. Sweating phase:
– Follows hot phase by 2–6 hours
– Fever resolves
– Marked fatigue and drowsiness,
warm, dry skin, tachycardia,
cough, severe headache,
nausea, vomiting, abdominal
pain, diarrhea, and delirium
– Lactic acidosis and
hypoglycemia (with falciparum
malaria)
– Anemia
– Splenomegaly
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 Diagnosis
 Recent advances
1. DNA or RNA probes by PCR
and rapid dipstick tests
o The dipstick have a
sensitivity of 88% and a
specificity of 97%;
2. Blood film
o Microscopy is still
considered the optimal test.
• Presence of parasites in the
blood 3 to 5 days after initiation
of therapy
o Suggests drug resistance
 The goal is to eradicate
the infection within 48 to
72 hours
• Along with avoidance of
complications such as
organ failure
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 Treatment
 Non-Pharmacologic
1. Insecticide treated nets
2. Indoor residual spraying
3. Vaccination
• The trial (Malawi, Ghana,
Kenya
o At 5-6months: 1st dose
o 1month apart: 2nd and 3rd
doses
o Second birth day 4th
 Pharmacologic
• Prophylaxis (MDA)?
o Areas of moderate to high
transmission of P.
falciparum
1. Prevalence greater than 10%, or
incidence greater than 250 cases
per 1000 population per year
2. Effect wanes in 1-3months
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Chemoprophylaxis

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Treatment

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 Treatment of severe malaria
• Altered consciousness (e.g.,
confusion, drowsiness, coma)
• Prostration, i.e. generalized
weakness
• Unable to eat or drink
• Repeated vomiting, resulting in
inability to retain oral
medication,
• Severe dehydration
• Convulsion or recent history of
convulsions
Danger signs
• Difficult breathing
• Jaundice (yellowish
discoloration of the eyes)
• Anemia (paleness of palms is
most reliable symptom in
children)
• Hemoglobinuria (cola colored
urine)
• Abnormal spontaneous
bleeding
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 Treatment of severe malaria
– Artesunate 2.4 mg/kg IV or
IM given on time = 0, 12h
and 24h, then daily for up
to five days
OR
– Artemether 3.2 mg/kg
loading dose on day 1
followed by 1.6 mg/kg daily
for two days
NB: A 10 mg of quinine dihydrochloride salt = 8.3 mg of quinine base
Alternative:
Quinine dihydrochloride
– Loading dose 20mg/kg quinine
salt in up to 500ml (5-10 ml/kg)
of NS or 5% DNS over 4 hours
(at a rate of no more than 5
mg/kg quinine salt per hour)
• Maintenance dose 12 hours
after the loading dose and then
8 hourly
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 Monitoring
• P. falciparum is associated with • Either hemofiltration or
serious complications; hemodiafiltration is indicated in
o Pulmonary edema, renal failure
hypoglycemia, jaundice, renal
failure, confusion, delirium,
seizures, coma, and death
• Careful monitoring of fluid
status and hemodynamic
parameters is mandatory.

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 Th
an
ky
ou
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