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• Cystoisospora belli Return to Top

• 1. Cystoisospora belli treatment

• 1.1 Immunocompetent hosts

• In the immunocompetent hosts, symptoms of Cystoisospora infection are usually self-limited.
• Antimicrobial therapy to immunocompetent patients may be considered if symptoms do not start to resolve spontaneously after 5 to 7 days (depending upon severity)

• Prefered regimen: Trimethoprim-sulfamethoxazole 160 mg/800 mg PO bid for 7-10 days
• Alternative regimen (1) (for patients who are allergic to or intolerant of TMP-SMX): Pyrimethamine 50-75 mg/day PO qd or divided in 2 equal doses AND Leucovorin 10–25 mg PO qd
• Alternative regimen (2): Ciprofloxacin 500 mg PO bid for 7 days (second-line alternative)

• 1.1.1 In pregnancy

• TMP-SMX should be avoided near-term because of the potential for hyperbilirubinemia and kernicterus in the newborn

• 1.1.2 During lactation

• TMP-SMX generally should be avoided by women when nursing infants who are premature, jaundiced, ill, or stressed, or who have glucose-6-phosphate dehydrogenase deficiency.

• 1.1.3 In pediatric patients

• The use of TMP-SMX in children less than 2 months of age generally is not recommended.

• 1.2 Immunocompromised hosts

• Preferred regimen (1): Trimethoprim-sulfamethoxazole 160 mg/800 mg PO/IV qid for 10 days
• Preferred regimen (2): Trimethoprim-sulfamethoxazole 160 mg/800 mg PO/IV bid for 7-10 days
• Note (1): One approach is to start with TMP-SMX (160 mg/800 mg) bid regimen first, and increase daily dose and/or duration (up to 3–4 weeks) if symptoms worsen or persist.
• Note (2): IV therapy is recommended for patients with potential or documented malabsorption.
• Alternative regimen (1): Pyrimethamine 50–75 mg PO qd AND Leucovorin 10–25 mg PO qd
• Alternative regimen (2): Ciprofloxacin 500 mg PO bid for 7 days

• 2. Cystoisospora belli prophylaxis

• 2.1 Primary prophylaxis

• Insufficient evidence is available to support a general recommendation for primary prophylaxis for Cystoisosporiasis per se, especially for U.S. travelers in isoporiasis-endemic areas.

• 2.2 Secondary prophylaxis (preventing recurrence in patients with CD4 count < 200 cells/mm³)

• Prefered regimen: Trimethoprim-sulfamethoxazole 160 mg/800 mg PO 3 times weekly
• Alternative regimen (1): Trimethoprim-sulfamethoxazole 160 mg/800 mg PO qd
• Alternative regimen (2): Trimethoprim-sulfamethoxazole 320 mg/1600 mg PO 3 times weekly
• Alternative regimen (3): Pyrimethamine 25 mg PO qd AND Leucovorin 5–10 mg PO qd
• Alternative regimen (4): Ciprofloxacin 500 mg PO 3 times weekly (second-line alternative)
• Note (1): Criteria for discontinuation of chronic maintenance therapy: sustained increase in CD4 count > 200 cells/mm³ for > 6 months in response to ART and without evidence of active Cystoisospora belli infection
• Note (2): Because of concerns about possible teratogenicity associated with first-trimester drug exposure, clinicians may withhold secondary prophylaxis during the first trimester and treat only symptomatic infection.

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• Immunocompetent

• Prefered regimen: Trimethoprim-sulfamethoxazole 160 mg/800 mg PO OR IV qid for 10 days

• 1. Patients with sulfa intolerance

• Alternative regimen (1): Pyrimethamine 50-75 mg PO daily AND Leucovorin 10–25 mg PO daily
• Alternative regimen (2): Ciprofloxacin 500 mg PO BID for 7 days

• HIV

• 1. Patients with CD4 Count <200/mm3 (chronic treatment)

• Prefered regimen: Trimethoprim-sulfamethoxazole 160 mg/800 mg PO 3 times weekly
• Alternative regimen (1): Trimethoprim-sulfamethoxazole 320 mg/1600 mg PO 3 times weekly
• Alternative regimen (2): Pyrimethamine 25 mg PO daily AND Leucovorin 5–10 mg PO daily
• Alternative regimen (3): Ciprofloxacin 500 mg PO 3 times weekly