Praziquantel 150 mg Cesol 150mg tablets | 6 tablet P s
Praziquantel 500 mg Cysticide 500mg tablets | 90 tablet P s
Metronidazole p. 542 is the drug of choice for acute invasive
amoebic dysentery since it is very effective against vegetative
forms of Entamoeba histolytica in ulcers. Tinidazole p. 544 is
also effective. Metronidazole and tinidazole are also active
against amoebae which may have migrated to the liver.
Treatment with metronidazole (or tinidazole) is followed by
a 10-day course of diloxanide furoate.
Diloxanide furoate is the drug of choice for asymptomatic
patients with E. histolytica cysts in the faeces; metronidazole
and tinidazole are relatively ineffective. Diloxanide furoate is
relatively free from toxic effects and the usual course is of
10 days, given alone for chronic infections or following
metronidazole or tinidazole treatment.
For amoebic abscesses of the liver metronidazole is
effective; tinidazole is an alternative. Aspiration of the
abscess is indicated where it is suspected that it may rupture
or where there is no improvement after 72 hours of
metronidazole; the aspiration may need to be repeated.
Aspiration aids penetration of metronidazole and, for
abscesses with more than 100 mL of pus, if carried out in
conjunction with drug therapy, may reduce the period of
Diloxanide furoate is not effective against hepatic
amoebiasis, but a 10-day course should be given at the
completion of metronidazole or tinidazole treatment to
destroy any amoebae in the gut.
Metronidazole is the treatment of choice for Trichomonas
vaginalis infection. Contact tracing is recommended and
sexual contacts should be treated simultaneously. If
metronidazole is ineffective, tinidazole may be tried.
Metronidazole is the treatment of choice for Giardia lamblia
infections. Alternative treatments are tinidazole or
mepacrine hydrochloride p. 505.
Cutaneous leishmaniasis frequently heals spontaneously but
if skin lesions are extensive or unsightly, treatment is
indicated, as it is in visceral leishmaniasis (kala-azar).
Leishmaniasis should be treated under specialist
Sodium stibogluconate below, an organic pentavalent
antimony compound, is used for visceral leishmaniasis. The
dosage varies with different geographical regions and expert
advice should be obtained. Some early non-inflamed lesions
of cutaneous leishmaniasis can be treated with intralesional
injections of sodium stibogluconate under specialist
Amphotericin p. 593 is used with or after an antimony
compound for visceral leishmaniasis unresponsive to the
antimonial alone; side-effects may be reduced by using
liposomal amphotericin (AmBisome ®). Abelcet ®, a lipid
formulation of amphotericin, is also likely to be effective but
less information is available.
response is often good, the relapse rate is high; it is
associated with serious side-effects. Other treatments
The prophylaxis and treatment of trypanosomiasis is difficult
and differs according to the strain of organism. Expert advice
patients with eye involvement (toxoplasma
choroidoretinitis), and those who are immunosuppressed.
Toxoplasmic encephalitis is a common complication of
AIDS. The treatment of choice is a combination of
pyrimethamine p. 620 and sulfadiazine p. 563, given for
several weeks (expert advice essential). Pyrimethamine is a
folate antagonist, and adverse reactions to this combination
are relatively common (folinic acid supplements and weekly
blood counts needed). Alternative regimens use
combinations of pyrimethamine with clindamycin p. 535 or
clarithromycin p. 538 or azithromycin p. 536. Long-term
secondary prophylaxis is required after treatment of
toxoplasmosis in immunocompromised patients;
prophylaxis should continue until immunity recovers.
If toxoplasmosis is acquired in pregnancy, transplacental
infection may lead to severe disease in the fetus; specialist
advice should be sought on management. Spiramycin
[unlicensed] (available from ‘special-order’ manufacturers or
specialist importing companies) may reduce the risk of
transmission of maternal infection to the fetus.
Other drugs used for Leishmaniasis Amphotericin, p. 593 . Pentamidine isetionate, p. 602
Visceral leishmaniasis (specialist use only)
▶ BY INTRAVENOUS INJECTION, OR BY INTRAMUSCULAR
▶ Adult: 20 mg/kg daily for 28 days
Cutaneous leishmaniasis (specialist use only)
▶ BY INTRAVENOUS INJECTION, OR BY INTRAMUSCULAR
▶ Adult: 20 mg/kg daily for 20 days
l CAUTIONS Heart disease (withdraw if conduction
disturbances occur). mucocutaneous disease . predisposition to QT interval prolongation .treat
intercurrent infection (e.g. pneumonia)
▶ Mucocutaneous disease Successful treatment of
mucocutaneous leishmaniasis may induce severe
inflammation around the lesions (may be life-threatening
if pharyngeal or tracheal involvement)—may require
l INTERACTIONS → Appendix 1: sodium stibogluconate
▶ Common or very common Abdominal pain . appetite
decreased . arthralgia . diarrhoea . headache . lethargy . malaise . myalgia . nausea . vomiting
606 Protozoal infection BNF 78
l PREGNANCY Manufacturer advises use only if potential
l BREAST FEEDING Amount probably too small to be
l HEPATIC IMPAIRMENT Manufacturer advises caution
(limited information available; abnormalities in hepatic
function may be expected in visceral leishmaniasis).
l RENAL IMPAIRMENT Avoid in significant impairment.
l MONITORING REQUIREMENTS Monitor ECG before and
l DIRECTIONS FOR ADMINISTRATION Intravenous injections
must be given slowly over 5 minutes (to reduce risk of local
thrombosis) and stopped if coughing or substernal pain
occur. Injection should be filtered immediately before
administration using a filter of 5 microns or less.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Pentostam (GlaxoSmithKline UK Ltd)
Antimony pentavalent (as Sodium stibogluconate) 100 mg per
1 ml Pentostam 10g/100ml solution for injection vials | 1 vial P £66.43
Artemether with lumefantrine p. 614 is licensed for the
treatment of acute uncomplicated falciparum malaria.
Artenimol with piperaquine phosphate p. 615 is not
recommended for the first-line treatment of acute
uncomplicated falciparum malaria because there is limited
experience of its use in travellers who usually reside in areas
where malaria is not endemic. Piperaquine has a long halflife.
Atovaquone with proguanil hydrochloride p. 615 is licensed
for the prophylaxis of falciparum malaria (for details, see
Recommended regimens for prophylaxis against malaria
p. 609) and for the treatment of acute, uncomplicated
Chloroquine p. 616 is usually used with proguanil
hydrochloride p. 618 for the prophylaxis of malaria in areas of
the world where there is little chloroquine resistance, but
this regimen may not give optimal protection (for details, see
Recommended regimens for prophylaxis against malaria
Guidelines for malaria prevention in travellers from the
United Kingdom (2018) published by Public Health England
state that patients already taking hydroxychloroquine
sulfate p. 1095 for another indication, and for whom
chloroquine would be an appropriate antimalarial, can
remain on hydroxychloroquine sulfate.
Chloroquine is no longer recommended for the treatment
of falciparum malaria owing to widespread resistance, nor is
it recommended if the infective species is not known or if the
infection is mixed; in these cases treatment should be with
quinine p. 619, atovaquone with proguanil hydrochloride
p. 615, or artemether with lumefantrine. It is still
recommended for the treatment of non-falciparum malaria.
Doxycycline p. 564 is used in adults and children over
12 years for the prophylaxis of malaria in areas of widespread
mefloquine or chloroquine resistance. Doxycycline is also used
as an alternative to mefloquine p. 617 or atovaquone with
proguanil hydrochloride p. 615 (for details, see
Recommended regimens for prophylaxis against malaria
Mefloquine is used for the prophylaxis of malaria in areas of
the world where there is a high risk of chloroquine-resistant
falciparum malaria (for details, see Recommended regimens
for prophylaxis against malaria p. 609).
Mefloquine is now rarely used for the treatment of
falciparum malaria because of increased resistance. It is
rarely used for the treatment of non-falciparum malaria
because better tolerated alternatives are available.
Mefloquine should not be used for treatment if it has been
Primaquine p. 618 is used to eliminate the liver stages of P.
vivax or P. ovale following chloroquine treatment.
Proguanil hydrochloride is usually used in combination with
chloroquine or atovaquone for the prophylaxis of malaria, (for
details, see Recommended regimens for prophylaxis against
Proguanil hydrochloride used alone is not suitable for the
treatment of malaria; however, atovaquone with proguanil
hydrochloride p. 615 is licensed for the treatment of acute
uncomplicated falciparum malaria. Atovaquone with
proguanil hydrochloride is also used for the prophylaxis of
falciparum malaria in areas of widespread mefloquine or
chloroquine resistance. Atovaquone with proguanil
hydrochloride is also used as an alternative to mefloquine or
doxycycline. Atovaquone with proguanil hydrochloride is
after leaving an endemic area.
Pyrimethamine p. 620 should not be used alone, but is used
Pyrimethamine with sulfadoxine is not recommended for
the prophylaxis of malaria, but can be used in the treatment of
falciparum malaria with (or following) quinine.
Quinine is not suitable for the prophylaxis of malaria.
Quinine is used for the treatment of falciparum malaria, if
the infective species is not known, or if the infection is mixed
(for details see Malaria, treatment p. 613).
All recommendations on prophylaxis against malaria reflect
guidelines agreed by UK malaria specialists, published in the
Public Health England Guidelines for malaria prevention in
travellers from the United Kingdom, 2018. The advice is
aimed at residents of the UK who travel to endemic areas.
Malaria, prophylaxis 12-Apr-2019
The recommendations on prophylaxis reflect guidelines
agreed by UK malaria specialists, published in the Public
Health England Guidelines for malaria prevention in
travellers from the United Kingdom, 2018. The advice is
aimed at residents of the UK who travel to endemic areas.
of drug for a particular individual should take into account:
. efficacy of the recommended drugs
. patient-related factors (e.g. age, pregnancy, renal or
hepatic impairment, compliance with prophylactic
For more information on choice of drug, see also
Prophylaxis is not absolute, and breakthrough infection
can occur with any of the drugs recommended. Personal
protection against being bitten is very important and is
recommended even in malaria-free areas as a preventive
measure against other insect vector-borne diseases.
Mosquito nets impregnated with permethrin p. 1237 provide
the most effective barrier protection against insects; mats
and vaporised insecticides are also useful. Diethyltoluamide
(DEET) 20–50% (available as sprays, and modified-release
polymer formulations) is safe and effective when applied to
the skin of adults and children over 2 months of age. It can
also be used during pregnancy and breast-feeding. However,
ingestion should be avoided, therefore breast-feeding
mothers should wash their hands and breast tissue before
handling infants. The duration of protection varies according
to the concentration of DEET and is longest for DEET 50%.
When sunscreen is also required, DEET should be applied
after the sunscreen. DEET reduces the SPF of sunscreen, so a
sunscreen of SPF 30–50 should be applied. If DEET is not
tolerated or is unavailable, see Public Health England
Guidelines for malaria prevention in travellers from the
United Kingdom for alternative options. Long sleeves and
trousers worn after dusk also provide protection against
In order to determine tolerance and to establish habit,
prophylaxis should generally be started before travel into an
endemic area; 1 week before travel for chloroquine p. 616
and proguanil hydrochloride p. 618; 2–3 weeks before travel
for mefloquine p. 617; and 1–2 days before travel for
atovaquone with proguanil hydrochloride p. 615 or
doxycycline p. 564. Prophylaxis should be continued for
4 weeks after leaving the area (except for atovaquone with
proguanil hydrochloride prophylaxis which should be
stopped 1 week after leaving). For extensive journeys across
different regions, the traveller must be protected in all areas
In those requiring long-term prophylaxis, chloroquine and
proguanil hydrochloride may be used. However there is
considerable concern over the protective efficacy of the
combination of chloroquine and proguanil hydrochloride in
certain areas where it was previously useful. Mefloquine is
licensed for use up to 1 year (although, if it is tolerated in the
short term, there is no evidence of harm when it is used for
up to 3 years). Doxycycline can be used for up to 2 years, and
atovaquone with proguanil hydrochloride for up to 1 year.
Prophylaxis with mefloquine, doxycycline, or atovaquone
with proguanil hydrochloride may be considered for longer
durations if it is justified by the risk of exposure to malaria.
Specialist advice should be sought for long-term
It is important to consider that any illness that occurs within
1 year and especially within 3 months of return might be
malaria even if all recommended precautions against
malaria were taken. Travellers should be warned of this and
told that if they develop any illness particularly within
3 months of their return they should see a doctor
immediately and specifically mention their exposure to
Both chloroquine and mefloquine are unsuitable for malaria
prophylaxis in individuals with a history of epilepsy. In these
patients, doxycycline or atovaquone with proguanil
hydrochloride may be used. However doxycycline may
interact with some antiepileptics and its dose may need to be
adjusted, see interactions information for doxycycline.
Asplenic individuals (or those with severe splenic
dysfunction) are at particular risk of severe malaria. If travel
to malarious areas is unavoidable, rigorous precautions are
required against contracting the disease.
Travel to malarious areas should be avoided during
pregnancy; if travel is unavoidable, effective prophylaxis
must be used. Chloroquine and proguanil hydrochloride can
be given in the usual doses during pregnancy, but these
drugs are not appropriate for most areas because their
effectiveness has declined. In the case of proguanil
hydrochloride, folic acid p. 1025 (dosed as a pregnancy at
’high-risk’ of neural tube defects) should be given for at least
the first trimester. If travelling to high risk areas or there is
resistance to other drugs, mefloquine may be considered
during the second or third trimester of pregnancy.
Mefloquine can be used in the first trimester with caution if
malaria prophylaxis if other regimens are unsuitable, and if
the entire course of doxycycline can be completed before
15 weeks’ gestation [unlicensed]. Atovaquone with proguanil
hydrochloride should be avoided during pregnancy,
however, it can be considered during the second and third
trimesters if there is no suitable alternative. Folic acid (dosed
as a pregnancy at ’high-risk’ of neural tube defects) should
be given if atovaquone with proguanil hydrochloride is used
Some antimalarials should be avoided when breast feeding,
see individual drugs for details.
Prophylaxis is required in breast-fed infants; although
antimalarials are present in milk, the amounts are too
variable to give reliable protection.
Travellers taking warfarin sodium p. 140 should begin
chemoprophylaxis 2–3 weeks before departure and the INR
should be stable before departure. It should be measured
before starting chemoprophylaxis, 7 days after starting, and
after completing the course. For prolonged stays, the INR
should be checked at regular intervals.
For additional information on malaria prophylaxis in
patients with other medical conditions, see Public Health
England Guidelines for malaria prevention in travellers from
Travellers visiting remote, malarious areas for prolonged
periods should carry standby treatment if they are likely to
In order to avoid excessive self-medication, the traveller
should be provided with written instructions that urgent
medical attention should be sought if fever (38°C or more)
develops 7 days (or more) after arriving in a malarious area
and that self-treatment is indicated if medical help is not
available within 24 hours of fever onset.
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