Isosporiasis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Trimethoprim-sulfamethoxazole is the drug of choice.

Medical Therapy

Antimicrobial Regimen

• 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.
• Ciprofloxacin should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

• 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.
• The American Academy of Pediatrics classifies Ciprofloxacin as usually compatible with breastfeeding, whereas the World Health Organization recommends avoiding Ciprofloxacin while breastfeeding and CDC recommends Ciprofloxacin should be used during lactation only if the potential benefit justifies the potential risk to the fetus.

• 1.1.3 In pediatric patients

• The use of TMP-SMX in children less than 2 months of age generally is not recommended.
• Available evidence is conflicting regarding the potential for growth defects and arthropathies in exposed children. Use of Ciprofloxacin in children requires assessment of potential risks and benefits.

• 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.