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Giardiasis Treatment & Management

  • Author: Hisham Nazer, MB, BCh, FRCP, , DTM&H; Chief Editor: Burt Cagir, MD, FACS  more...
Updated: Feb 15, 2016

Approach Considerations

Standard treatment for giardiasis consists of antibiotic therapy.[59] Metronidazole is the most commonly prescribed antibiotic for this condition.[31, 60, 61]  However, metronidazole use has been associated with significant failure rates in clearing parasites from the gut and with poor patient compliance.[62] In addition, an increasing incidence of nitroimidazole-refractory giardiasis has been reported, particularly in travelers from India.[63]  

Real-time polymerase chain reaction (PCR) may aid in the evaluation of treatment success. van den Bijllaardt et al showed it took about 1 week for samples to become negative after treatment of a G lamblia infection, indicating rapid clearance of the parasitic DNA following successful therapy.[64]

Appropriate fluid and electrolyte management is critical, particularly in patients with large-volume diarrheal losses.[6]

Treat children with acute or chronic diarrhea who manifest a failure to thrive, malabsorption, or other GI tract symptoms in whom Giardia organisms have been identified.[57]

Generally, do not treat asymptomatic persons who excrete the organism, except to prevent household transmission (eg, from toddlers to pregnant women or to patients with hypogammaglobulinemia or cystic fibrosis) and to permit adequate treatment in individuals with possible Giardia intestinalis –associated antibiotic malabsorption who require oral antibiotic treatment for other infections.[35, 65]

Routine treatment of infected persons in highly endemic areas where water supplies continue to be contaminated is of questionable value because reinfection may readily occur.[15, 66] Treat all infected persons who are in nonendemic areas.[67]

Ensure that close contacts of the patient are also examined for giardiasis and treated if infected.

Severely dehydrated or malnourished patients should be admitted for further care.

Diet and Activity

No special diet is required. A significant portion of patients have symptoms of lactose intolerance (cramping, bloating, diarrhea), and maintenance on a lactose-free diet for several months may be helpful. Acquired lactose intolerance occurs in as many as 20-40% of cases.[9]

Activity restrictions are not indicated. However, infected subjects who are at risk of spreading the infection should be isolated and treated.

Pregnant Patients

No consistent recommendations exist for the treatment of pregnant patients because of the potential adverse effects of anti-Giardia agents on the fetus. If possible, treatment should be avoided during the first trimester. Mildly symptomatic women should have treatment delayed until after delivery. If treatment is necessary, paromomycin can be used as systemic absorption is poor.[66] If the patient is left untreated, adequate nutrition and hydration maintenance are paramount.

Failed Treatment

Documenting the continued presence of Giardia in patients who appear unresponsive to treatment is important. A significant number of patients develop post-Giardia lactose intolerance and present with symptoms consistent with persistent infection. These patients usually improve with time and with the institution of a lactose-free diet.

If Giardia is found in the patient, a careful history should indicate whether this is a reinfection or a treatment failure. A second course of the same drug, for a longer period or a higher dose, should be effective in reinfections, whereas the use of an alternative drug should be effective in true treatment failures. A combination therapy may have to be implemented in certain cases of treatment failure.

Patients who fail repeated courses of treatment should be evaluated for hypogammaglobulinemia and may require combination therapy or chronic suppressive therapy.


Infected persons and persons at risk should carefully wash their hands after they have any contact with feces. Careful hand washing is important, especially for caregivers of diapered infants in daycare centers, where diarrhea is common and carriers of Giardia organisms are numerous.

Chlorination, sedimentation, and filtration methods should be implemented to adequately purify public water supplies. Effective chlorine inactivation of Giardia cysts in water requires an optimal chlorine concentration, water pH, turbidity, temperature, and contact time. These variables cannot be appropriately controlled in all municipalities, and they are particularly difficult to control in swimming pools.

Advise travelers to endemic areas to avoid eating uncooked foods that may have been grown, washed, or prepared with contaminated water.

Drinking water can be purified by using filtration (pore size, < 1 µm) or by briskly boiling water for at least 5 minutes. Chlorine or iodine water treatments are less effective than boiling or filtration, but they may be used as alternatives when other methods are not available.

Infected individuals should refrain from using recreational water venues (eg, swimming pools, lakes, rivers) until they are symptom-free for few few weeks.

Breastfeeding appears to protect infants from Giardia intestinalis infection.[9, 15, 17] Breast milk contains detectable titres of secretory IgA, which is protective for infants, especially in developing countries. A study from Egypt[68] showed breast-fed infants had a lower incidence of symptomatic and asymptomatic infection. Furthermore, infected infants who were exclusively breast-fed had fewer clinical manifestations than those who were not exclusively breast-fed.

Contributor Information and Disclosures

Hisham Nazer, MB, BCh, FRCP, , DTM&H Professor of Pediatrics, Consultant in Pediatric Gastroenterology, Hepatology and Clinical Nutrition, University of Jordan Faculty of Medicine, Jordan

Hisham Nazer, MB, BCh, FRCP, , DTM&H is a member of the following medical societies: American Association for Physician Leadership, Royal College of Paediatrics and Child Health, Royal College of Surgeons in Ireland, Royal Society of Tropical Medicine and Hygiene, Royal College of Physicians and Surgeons of the United Kingdom

Disclosure: Nothing to disclose.

Chief Editor

Burt Cagir, MD, FACS Clinical Professor of Surgery, The Commonwealth Medical College; Attending Surgeon, Assistant Program Director, Robert Packer Hospital; Attending Surgeon, Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.


Manoop S Bhutani, MD Professor, Co-Director, Center for Endoscopic Research, Training and Innovation (CERTAIN), Director, Center for Endoscopic Ultrasound, Department of Medicine, Division of Gastroenterology, University of Texas Medical Branch; Director, Endoscopic Research and Development, The University of Texas MD Anderson Cancer Center

Manoop S Bhutani, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Institute of Ultrasound in Medicine, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Brooks D Cash, MD, FACP Director of Clinical Research, Assistant Professor of Medicine, Division of Gastroenterology, National Naval Medical Center

Brooks D Cash, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Glenn Fennelly, MD, MPH Director, Division of Infectious Diseases, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center; Clinical Associate Professor of Pediatrics, Albert Einstein College of Medicine

Glenn Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Murat Hökelek, MD, PhD Technical Consultant of Parasitology Laboratory, Professor, Department of Clinical Microbiology, Ondokuz Mayis University Medical School, Turkey

Murat Hökelek, MD, PhD is a member of the following medical societies: Turkish Society for Parasitology

Disclosure: Nothing to disclose.

Mark H Johnston, MD Associate Professor of Medicine, Uniformed Services University of Health Sciences; Consulting Staff, Lancaster Gastroenterology Inc

Mark H Johnston, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Michael D Nissen, MBBS, FRACP, FRCPA Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital

Michael D Nissen, MBBS, FRACP, FRCPA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Pediatric Infectious Diseases Society, Royal Australasian College of Physicians, and Royal College of Pathologists of Australasia

Disclosure: Nothing to disclose.

Andre Pennardt, MD, FACEP, FAAEM, FAWM Clinical Associate Professor of Emergency Medicine, Medical College of Georgia; Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Departments of Emergency Medicine, Aviation Medicine and Dive Medicine, Womack Army Medical Center

Andre Pennardt, MD, FACEP, FAAEM, FAWM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US, International Society for Mountain Medicine, National Association of EMS Physicians, Special Operations Medical Association, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Giardia lamblia, cyst form.
Giardia lamblia trophozoites in culture.
A Giardia intestinalis cyst.
Giardia intestinalis trophozoites on stool examination from a patient with diarrhea.
Giardia trophozoite
Giardia cyst.
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