treatment of mild to moderate disease [unlicensed
A combination of clindamycin p. 535 and primaquine
p. 618 by mouth is used in the treatment of mild to moderate
disease [unlicensed indication]; this combination is
associated with considerable toxicity.
Co-trimoxazole in high dosage, given by mouth or by
intravenous infusion, is the drug of choice for the treatment
of severe pneumocystis pneumonia. Pentamidine isetionate
below given by intravenous infusion is an alternative for
patients who cannot tolerate co-trimoxazole, or who have
not responded to it. Pentamidine isetionate is a potentially
toxic drug that can cause severe hypotension during or
Corticosteroid treatment can be lifesaving in those with
severe pneumocystis pneumonia.
In moderate to severe infections associated with HIV
infection, prednisolone p. 678 is given by mouth for 5 days
(alternatively, hydrocortisone p. 676 may be given
parenterally); the dose is then reduced to complete 21 days
of treatment. Corticosteroid treatment should ideally be
started at the same time as the anti-pneumocystis therapy
and certainly no later than 24–72 hours afterwards. The
corticosteroid should be withdrawn before antipneumocystis treatment is complete.
Prophylaxis against pneumocystis pneumonia should be
given to all patients with a history of the infection.
Prophylaxis against pneumocystis pneumonia should also be
considered for severely immunocompromised patients.
Prophylaxis should continue until immunity recovers
sufficiently. It should not be discontinued if the patient has
oral candidiasis, continues to lose weight, or is receiving
cytotoxic therapy or long-term immunosuppressant therapy.
Co-trimoxazole by mouth is the drug of choice for
prophylaxis against pneumocystis pneumonia. It is given
daily or on alternate days (3 times a week); the dose may be
Inhaled pentamidine isetionate is better tolerated than
parenteral pentamidine isetionate. Intermittent inhalation
of pentamidine isetionate is used for prophylaxis against
extrapulmonary infection. Alternatively, dapsone can be
used. Atovaquone has also been used for prophylaxis
Treatment of mild to moderate Pneumocystis jirovecii
(Pneumocystis carinii) pneumonia in patients intolerant
▶ Adult: 750 mg twice daily for 21 days, dose to be taken
with food, particularly high fat food
Prophylaxis against pneumocystis pneumonia
l UNLICENSED USE Not licensed for prophylaxis against
l CAUTIONS Other causes of pulmonary disease should be
sought and treated . elderly . initial diarrhoea and difficulty
in taking with food may reduce absorption (and require
l INTERACTIONS → Appendix 1: antimalarials
reactions .throat tightness . vomiting
▶ Frequency not known Stevens-Johnson syndrome
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—no information available.
l BREAST FEEDING Manufacturer advises avoid.
l HEPATIC IMPAIRMENT Manufacturer advises use with
caution in significant impairment and monitor closely—no
l RENAL IMPAIRMENT Manufacturer advises caution.
Monitoring Monitor more closely in renal impairment.
l PRESCRIBING AND DISPENSING INFORMATION Flavours of
oral liquid formulations may include tutti-frutti.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 21
▶ Wellvone (GlaxoSmithKline UK Ltd)
Atovaquone 150 mg per 1 ml Wellvone 750mg/5ml oral suspension
sugar-free | 226 ml P £486.37 DT = £486.37
Treatment of Pneumocystis jirovecii (Pneumocystis
carinii) pneumonia (specialist use only)
▶ Adult: 4 mg/kg once daily for at least 14 days
Prophylaxis of Pneumocystis jirovecii (Pneumocystis
carinii) pneumonia (specialist use only)
▶ BY INHALATION OF NEBULISED SOLUTION
▶ Adult: 300 mg every 4 weeks, alternatively 150 mg
every 2 weeks, using suitable equipment—consult
Visceral leishmaniasis (specialist use only)
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 3–4 mg/kg once daily on alternate days,
maximum total of 10 injections, course may be
Cutaneous leishmaniasis (specialist use only)
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 3–4 mg/kg 1–2 times a week until condition
Trypanosomiasis (specialist use only)
▶ BY DEEP INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
▶ Adult: 4 mg/kg once daily or on alternate days for a
l UNLICENSED USE Not licensed for primary prevention of
Pneumocystis jirovecii (Pneumocystis carinii) pneumonia by
inhalation of nebulised solution.
severe hypotension following administration . thrombocytopenia
l INTERACTIONS → Appendix 1: pentamidine
▶ Common or very common Dizziness . hypoglycaemia (can
be severe and sometimes fatal). hypotension (can be
severe and sometimes fatal). local reaction . nausea .rash . taste altered
▶ Rare or very rare QT interval prolongation
▶ Frequency not known Pancreatitis acute (can be severe and
▶ When used by inhalation Cough . dyspnoea .respiratory
▶ With parenteral use Arrhythmia (can be severe and
sometimes fatal). pancreatitis (can be severe and
▶ When used by inhalation Angioedema . appetite decreased . bradycardia . fatigue .renal failure
l PREGNANCY Manufacturer advises avoid unless essential.
l BREAST FEEDING Manufacturer advises avoid unless
essential—no information available.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments Reduce intravenous dose for
pneumocystis pneumonia if creatinine clearance less than
10 mL/minute: in life-threatening infection, use 4 mg/kg
once daily for 7–10 days, then 4 mg/kg on alternate days to
complete course of at least 14 doses; in less severe infection,
use 4 mg/kg on alternate days for at least 14 doses.
▶ Monitor blood pressure before starting treatment, during
administration, and at regular intervals, until treatment
▶ Carry out laboratory monitoring according to product
l DIRECTIONS FOR ADMINISTRATION Patient should be lying
down when receiving drug parenterally. Direct intravenous
injection should be avoided whenever possible and never
given rapidly; intramuscular injections should be deep and
preferably given into the buttock. For intravenous infusion,
reconstitute 300 mg with 3–5 mL Water for Injections
(displacement value may be significant), then dilute
required dose with 50–250 mL Glucose 5% or Sodium
Chloride 0.9%; give over at least 60 minutes.
Powder for injection (dissolved in water for injection)
l HANDLING AND STORAGE Pentamidine isetionate is toxic
and personnel should be adequately protected during
handling and administration—consult product literature.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for injection
Pentamidine isetionate 300 mg Pentacarinat 300mg powder for
solution for injection vials | 5 vial P £158.86
Advice on prophylaxis and treatment of helminth infections
is available from the following specialist centres:
Scotland Contact local Infectious Diseases Unit
London 0845 155 5000 (treatment)
Anthelmintics are effective in threadworm (pinworms,
Enterobius vermicularis) infections, but their use needs to be
Adult threadworms do not live for longer than 6 weeks and
for development of fresh worms, ova must be swallowed and
exposed to the action of digestive juices in the upper
intestinal tract. Direct multiplication of worms does not take
place in the large bowel. Adult female worms lay ova on the
perianal skin which causes pruritus; scratching the area then
leads to ova being transmitted on fingers to the mouth, often
via food eaten with unwashed hands. Washing hands and
scrubbing nails before each meal and after each visit to the
toilet is essential. A bath taken immediately after rising will
remove ova laid during the night.
Mebendazole p. 605 is the drug of choice for treating
threadworm infection in patients of all ages over 6 months.
It is given as a single dose; as reinfection is very common, a
second dose may be given after 2 weeks.
Ascaricides (common roundworm infections)
Mebendazole is effective against Ascaris lumbricoides and is
generally considered to be the drug of choice.
an alternative when mebendazole cannot be used. It is very
Niclosamide [unlicensed] (available from ‘special-order’
manufacturers or specialist importing companies) is the
lightheadedness, and pruritus; it is not effective against
larval worms. Fears of developing cysticercosis in Taenia
solium infections have proved unfounded. All the same, an
antiemetic can be given before treatment and a laxative can
be given 2 hours after niclosamide.
Cysts caused by Echinococcus granulosus grow slowly and
asymptomatic patients do not always require treatment.
Surgical treatment remains the method of choice in many
situations. Albendazole p. 604 [unlicensed] (available from
‘special-order’ manufacturers or specialist importing
companies) is used in conjunction with surgery to reduce the
risk of recurrence or as primary treatment in inoperable
cases. Alveolar echinococcosis due to E. multilocularis is
usually fatal if untreated. Surgical removal with albendazole
cover is the treatment of choice, but where effective surgery
is impossible, repeated cycles of albendazole (for a year or
more) may help. Careful monitoring of liver function is
particularly important during drug treatment.
Hookworms (ancylostomiasis, necatoriasis) live in the upper
small intestine and draw blood from the point of their
attachment to their host. An iron-deficiency anaemia may
occur and, if present, effective treatment of the infection
requires not only expulsion of the worms but treatment of
Mebendazole has a useful broad-spectrum activity, and is
effective against hookworms. Albendazole [unlicensed]
(available from ‘special-order’ manufacturers or specialist
importing companies) is an alternative. Levamisole is also is
Schistosomicides (bilharziasis)
mesentery. S. japonicum is more widely distributed in veins
of the alimentary tract and portal system.
Praziquantel [unlicensed] is available from Merck Serono
(Cysticide ®) and is effective against all human schistosomes.
No serious adverse effects have been reported. Of all the
available schistosomicides, it has the most attractive
combination of effectiveness, broad-spectrum activity, and
effective against microfilariae and adults of Loa loa,
Wuchereria bancrofti, and Brugia malayi. To minimise
reactions, treatment in adults and children over 1 month, is
commenced with a dose of diethylcarbamazine citrate on the
first day and increased gradually over 3 days. Length of
treatment varies according to infection type, and usually
gives a radical cure for these infections. Close medical
supervision is necessary particularly in the early phase of
In heavy infections there may be a febrile reaction, and in
heavy Loa loa infection there is a small risk of
encephalopathy. In such cases specialist advice should be
very effective in onchocerciasis and it is now the drug of
choice; reactions are usually slight. Diethylcarbamazine or
suramin should no longer be used for onchocerciasis because
Cutaneous larva migrans (creeping eruption)
Dog and cat hookworm larvae may enter human skin where
they produce slowly extending itching tracks usually on the
foot. Single tracks can be treated with topical tiabendazole
(no commercial preparation available). Multiple infections
respond to ivermectin, albendazole or tiabendazole
(thiabendazole) by mouth [all unlicensed] (available from
‘special-order’ manufacturers or specialist importing
Adult Strongyloides stercoralis live in the gut and produce
larvae which penetrate the gut wall and invade the tissues,
setting up a cycle of auto-infection. Ivermectin [unlicensed]
(available from ‘special-order’ manufacturers or specialist
importing companies) is the treatment of choice for chronic
Strongyloides infection in adults and children over 5 years.
Albendazole [unlicensed] (available from ‘special order’
manufacturers or specialist importing companies) is an
alternative given to adults and children over 2 years.
Chronic Strongyloides infection
▶ Adult: 400 mg twice daily for 3 days, dose may be
repeated after 3 weeks if necessary
Hydatid disease, in conjunction with surgery to reduce the
risk of recurrence or as primary treatment in inoperable
▶ Adult: (consult product literature)
l UNLICENSED USE Albendazole is an unlicensed drug.
l INTERACTIONS → Appendix 1: albendazole
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet, chewable
CAUTIONARY AND ADVISORY LABELS 9
▶ Eskazole (Imported (France))
Albendazole 400 mg Eskazole 400mg tablets | 60 tablet P s
CAUTIONARY AND ADVISORY LABELS 9
Albendazole 200 mg Zentel 200mg chewable tablets | 6 tablet P s
Albendazole 400 mg Zentel 400mg chewable tablets |
Wuchereria bancrofti infections | Brugia malayi infections
▶ Adult: Initially 1 mg/kg daily on the first day, then
increased to 6 mg/kg daily in divided doses, dose to be
increased gradually over 3 days
▶ Adult: Initially 1 mg/kg daily on the first day, then
increased to 6 mg/kg daily in divided doses, dose to be
increased gradually over 3 days; maximum 9 mg/kg per
l UNLICENSED USE Diethylcarbamazine is an unlicensed
l MEDICINAL FORMS No licensed medicines listed.
Chronic Strongyloides infection
▶ Adult: 200 micrograms/kg daily for 2 days
▶ Adult: 150 micrograms/kg for 1 dose, retreatment at
intervals of 6 to 12 months, depending on symptoms,
must be given until the adult worms die out
Scabies, in combination with topical drugs, for the
treatment of hyperkeratotic (crusted or ‘Norwegian’)
scabies that does not respond to topical treatment alone
▶ Adult: 200 micrograms/kg for 1 dose, further doses of
200 micrograms/kg may be required
l UNLICENSED USE Ivermectin is unlicensed.
l INTERACTIONS → Appendix 1: ivermectin
▶ Common or very common Skin reactions
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet
▶ Stromectol (Imported (France))
Ivermectin 3 mg Stromectol 3mg tablets | 4 tablet P s
▶ Adult: 120–150 mg for 1 dose
l UNLICENSED USE Not licensed.
l CONTRA-INDICATIONS Blood disorders
l CAUTIONS Epilepsy . Sjögren’s syndrome
l INTERACTIONS → Appendix 1: levamisole
l SIDE-EFFECTS Arthralgia (long term use). blood disorder
use). myalgia (long term use). nausea .rash (long term
use). seizure (long term use).taste altered (long term use) . vasculitis (long term use). vomiting
l PREGNANCY Embryotoxic in animal studies, avoid if
l BREAST FEEDING No information available.
Dose adjustments Use with caution—dose adjustment may
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet
CAUTIONARY AND ADVISORY LABELS 4
▶ Ergamisol (Imported (Belgium))
Levamisole (as Levamisole hydrochloride) 50 mg Ergamisol 50mg
▶ Child 6 months–17 years: 100 mg for 1 dose, if
reinfection occurs, second dose may be needed after
▶ Adult: 100 mg for 1 dose, if reinfection occurs, second
dose may be needed after 2 weeks
Whipworm infections | Hookworm infections
▶ Child 1–17 years: 100 mg twice daily for 3 days
▶ Adult: 100 mg twice daily for 3 days
▶ Child 1 year: 100 mg twice daily for 3 days
▶ Child 2–17 years: 100 mg twice daily for 3 days,
alternatively 500 mg for 1 dose
▶ Adult: 100 mg twice daily for 3 days, alternatively
l UNLICENSED USE Not licensed for use as a single dose of
500 mg in roundworm infections.
▶ In children Not licensed for use in children under 2 years.
l INTERACTIONS → Appendix 1: mebendazole
▶ Common or very common Gastrointestinal discomfort
▶ Uncommon Diarrhoea . flatulence
l PREGNANCY Manufacturer advises avoid—toxicity in
l BREAST FEEDING Amount present in milk too small to be
harmful but manufacturer advises avoid.
l PRESCRIBING AND DISPENSING INFORMATION Flavours of
oral liquid formulations may include banana.
Medicines for Children leaflet: Mebendazole for worm infections
www.medicinesforchildren.org.uk/mebendazole-worminfections
l EXCEPTIONS TO LEGAL CATEGORY Mebendazole tablets can
be sold to the public if supplied for oral use in the
treatment of enterobiasis in adults and children over
2 years provided its container or package is labelled to
show a max. single dose of 100 mg and it is supplied in a
container or package containing not more than 800 mg.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Mebendazole 20 mg per 1 ml Vermox 100mg/5ml oral suspension
Mebendazole 100 mg Vermox 100mg chewable tablets sugar-free | 6 tablet P £1.34 DT = £1.34
Tapeworm infections (Taenia solium)
▶ Adult: 5–10 mg/kg for 1 dose, to be taken after a light
Tapeworm infections (Hymenolepis nana)
▶ Adult: 25 mg/kg for 1 dose, to be taken after a light
Schistosoma haematobium worm infections | Schistosoma
▶ Adult: 20 mg/kg, followed by 20 mg/kg after 4–6 hours
Schistosoma japonicum worm infections
▶ Adult: 20 mg/kg 3 times a day for 1 day
l UNLICENSED USE Praziquantel is an unlicensed drug.
l INTERACTIONS → Appendix 1: praziquantel
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet
▶ Praziquantel (Imported (Germany))
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