Toxoplasmosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief:

Overveiw

Treatment of immunocompetent adults with lymphadenopathic toxoplasmosis is rarely indicated. Treatment for ocular diseases should be based on a complete ophthalmologic evaluation.When a pregnant woman is diagnosed with acute toxoplasmosis, amniocentesis can be used to determine whether the fetus has been infected or not.If the parasite has not yet reached the fetus, spiramycin can help to prevent placental transmission. If the fetus has been infected, the pregnant woman can be treated with pyrimethamine and sulfadiazine, with folinic acid, after the first trimester. Persons with AIDS who develop active toxoplasmosis (usually toxoplasmic enchephalitis) need treatment that must be taken until a significant immunologic improvement is achieved as a result of antiretroviral therapy.

Medical Therapy

Treatment of immunocompetent adults with lymphadenopathic toxoplasmosis is rarely indicated. Treatment for ocular diseases should be based on a complete ophthalmologic evaluation.When a pregnant woman is diagnosed with acute toxoplasmosis, amniocentesis can be used to determine whether the fetus has been infected or not.If the parasite has not yet reached the fetus, spiramycin can help to prevent placental transmission. If the fetus has been infected, the pregnant woman can be treated with pyrimethamine and sulfadiazine, with folinic acid, after the first trimester. Persons with AIDS who develop active toxoplasmosis (usually toxoplasmic enchephalitis) need treatment that must be taken until a significant immunologic improvement is achieved as a result of antiretroviral therapy.

Antimicrobial Regimen

• Toxoplasma gondii (treatment)

• 1. Lymphadenopathic toxoplasmosis

• Preferred regimen: Treatment of immunocompetent adults with lymphadenopathic toxoplasmosis is rarely indicated; this form of the disease is usually self-limited.

• 2. Ocular disease

• 2.1 Adults

• *1. Pathogen-directed antimicrobial therapy

• Preferred regimen: Pyrimethamine 200 mg PO qd on day 1 then 50-75 mg PO qd for 2 weeks beyond resolution of symptoms AND Sulfadiazine 1-1.5 g PO qid for 2 weeks beyond resolution of symptoms AND Leucovorin (Folinic acid) 5-20 mg PO 3 times/week for 3 weeks beyond resolution of symptoms

• 2.2 Pediatric

• Preferred regimen: Pyrimethamine 2 mg/kg PO first day then 1 mg/kg each day AND Sulfadiazine 50 mg/kg PO bid AND folinic acid (Leucovorin 7.5 mg/day PO ) for 4 to 6 weeks followed by reevaluation of the patient's condition
• Alternative regimen: The fixed combination of Trimethoprim with Sulfamethoxazole has been used as an alternative.
• Note: If the patient has a hypersensitivity reaction to sulfa drugs, Pyrimethamine AND Clindamycin can be used instead.

• 3. Maternal and fetal infection

• 3.1 First and early second trimesters

• Preferred regimen: Spiramycin is recommended

• 3.2 Late second and third trimesters

• Preferred regimen: Pyrimethamine/Sulfadiazine AND Leucovorin for women with acute T. gondii infection diagnosed at a reference laboratory during gestation.

• 3.3 Infant

• Note: If the infant is likely to be infected, then treatment with drugs such as Pyrimethamine, Atovaquone, Sulfadiazine, Leucovorin is typical. Congenitally infected newborns are generally treated with pyrimethamine, a sulfonamide, and leucovorin for 1 year.

• 4. Toxoplasma gondii Encephalitis in AIDS

• 4.1 Treatment for acute infection

• 4.1.1 Patients with weight <60 kg
• Preferred regimen: Pyrimethamine 200 mg PO 1 time, followed by Pyrimethamine 50 mg PO qd AND Atovaquone AND Sulfadiazine 1000 mg PO q6h AND Leucovorin 10–25 mg PO qd,
• 4.1.2 Patients with weight ≥60 kg

• Preferred regimen: Pyrimethamine 200 mg PO 1 time, followed by Pyrimethamine 75 mg PO qd AND Sulfadiazine 1500 mg PO q6h AND Leucovorin 10–25 mg PO qd and Leucovorin dose can be increased to 50 mg qd or bid
• Alternative regimen (1): Pyrimethamine AND Leucovorin AND Clindamycin 600 mg IV/ PO q6h
• Alternative regimen (2): TMP-SMX (TMP 5 mg/kg and SMX 25 mg/kg ) IV/PO bid
• Alternative regimen (3): Atovaquone 1500 mg PO bid AND Pyrimethamine AND Leucovorin
• Alternative regimen (4): Atovaquone1500 mg PO bid AND sulfadiazine 1000–1500 mg PO q6h (weight-based dosing, as in preferred therapy)
• Alternative regimen (5): Atovaquone 1500 mg PO bid
• Alternative regimen (6): Pyrimethamine AND Leucovorin AND Azithromycin 900–1200 mg PO qd
• Note: Treatment for at least 6 weeks; longer duration if clinical or radiologic disease is extensive or response is incomplete at 6 weeks.

• 4.2 Chronic maintenance therapy

• Preferred regimen: Pyrimethamine 25–50 mg PO qd AND sulfadiazine 2000–4000 mg PO qd (in 2–4 divided doses) AND Leucovorin 10–25 mg PO qd
• Alternative regimen (1): Clindamycin 600 mg PO q8h AND (Pyrimethamine 25–50 mg AND Leucovorin 10–25 mg) PO qd
• Alternative regimen (2): TMP-SMX DS 1 tablet bid
• Alternative regimen (3): Atovaquone 750–1500 mg PO bid AND (Pyrimethamine 25 mg AND Leucovorin 10 mg) PO qd
• Alternative regimen (4): Atovaquone 750–1500 mg PO bid
• Alternative regimen (5): Sulfadiazine 2000–4000 mg PO bid/qid
• Alternative regimen (6): Atovaquone 750–1500 mg PO bid Pyrimethamine and Leucovorin doses are the same as for preferred therapy
• Note: Adjunctive corticosteroids (e.g., Dexamethasone) should only be administered when clinically indicated to treat mass effect associated with focal lesions or associated edema; discontinue as soon as clinically feasible. Anticonvulsants should be administered to patients with a history of seizures and continued through acute treatment, but should not be used as seizure prophylaxis . If Clindamycin is used in place of Sulfadiazine, additional therapy must be added to prevent PCP.

• Toxoplasma gondii (prophylaxis)

• 1. Prophylaxis to prevent first episode of encephalitis in AIDS

• 1.1 Indications

• Toxoplasma IgG-positive patients with CD4 count <100 cells/µL
• Seronegative patients receiving PCP prophylaxis not active against toxoplasmosis should have toxoplasma serology retested if CD4 count decline to <100 cells/µL. Prophylaxis should be initiated if seroconversion occurred.

• 1.2 Prophylactic therapy

• Preferred regimen: TMP-SMX 1 DS PO daily
• Alternative regimen (1): TMP-SMX 1 DS PO three times weekly
• Alternative regimen (2): TMP-SMX 1 SS PO qd
• Alternative regimen (3): Dapsone 50 mg PO qd AND (Pyrimethamine 50 mg PO AND Leucovorin 25 mg) PO weekly
• Alternative regimen (4): Dapsone 200 mg PO AND Pyrimethamine 75 mg PO AND Leucovorin 25 mg PO weekly
• Alternative regimen (5): Atovaquone 1500 mg PO qd
• Alternative regimen (6): Atovaquone 1500 mg PO AND Pyrimethamine 25 mg PO AND Leucovorin 10 mg PO qd

References

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