Cryptosporidiosis Treatment & Management
- Author: Miguel M Cabada, MD, MSc; Chief Editor: Michael Stuart Bronze, MD more...
Optimal therapy for cryptosporidiosis includes attention to fluids and electrolytes, antimotility agents, antiparasitic drugs, nutritional support, and/or reversal of immunosuppression.[1, 2]
Attention to the nutritional aspects of patient care, to avoid potentially fatal malnutrition, is crucial. Mature epithelial cells at the tips of the villi are preferentially lost; hence, enzymes expressed on these cells (including lactase) are also lost. This leads to secondary lactose intolerance. Therefore, supportive care should include a lactose-free diet. Enteral nutrition is usually sufficient; studies have not supported the use of parenteral nutrition. Infection may improve with nutritional supplementation, particularly with regimens including zinc or glutamine.
Patients with acalculous cholecystitis should generally be treated with cholecystectomy.
The following specialists should be consulted:
- Infectious disease specialist - For consideration of antiparasitic and antiretroviral therapy
- Gastroenterologist - For ERCP and sphincterotomy; endoscopy is sometimes required for diagnosis
- General surgeon - For suspected acalculous cholecystitis
Trials of antiparasitic drugs in patients with AIDS and cryptosporidiosis have been disappointing. Nitazoxanide, paromomycin, and azithromycin are partially active. Combination antiretroviral therapy that includes an HIV protease inhibitor is associated with dramatic improvement in many cases.[1, 2] Improvement is likely to result from immune reconstitution but may, in part, reflect the antiparasitic activity of protease inhibitors. Use of partially active antiparasitic drugs (eg, nitazoxanide or paromomycin combined with azithromycin) should be considered along with initiating antiretroviral therapy.[28, 29, 30, 31, 32]
However, in patients with AIDS, cryptosporidiosis usually cannot be eradicated prior to restoration of the CD4 cell count in response to combination antiretroviral therapy. During early immune reconstitution, patients should generally continue antiparasitic therapy (eg, nitazoxanide or paromomycin) and antimotility agents, as needed.[28, 31]
Symptomatic therapy includes replacement of fluids, provision of appropriate nutrition, and treatment with antimotility agents. Loperamide or diphenoxylate-atropine may help in some cases. More potent opiates, including anhydrous morphine (Paregoric), may work in some cases that fail to respond to milder agents.
Octreotide, a somatostatin analogue and substance P antagonist, suppresses diarrhea in chronic cryptosporidiosis.
Fluid and electrolyte loss
Replacement of fluids and electrolytes is the critically important first step in the management of cryptosporidiosis, particularly in patients with large diarrheal losses. Fluids should include sodium, potassium, bicarbonate, and glucose. Oral rehydration is the preferred mode, but severely ill patients may require parenteral fluids.
Biliary involvement in cryptosporidiosis requires specific interventions. Acalculous cholecystitis should be treated with cholecystectomy.
Patients with sclerosing cholangitis can usually be treated with endoscopic retrograde cholangiopancreatography (ERCP), although sphincterotomy may result in temporary relief. In selected cases, recurrence may be prevented by placing a stent.
Prevention of Cryptosporidiosis
Water purification is the most important public health measure in the prevention of cryptosporidiosis.[31, 33] Because chlorination has little effect on the oocysts, water purification should involve flocculation and filtration (using filters with a pore size of 1-4 μm). Ultraviolet radiation and ozonization are other means of disinfecting contaminated water. Decontamination can also be achieved by bringing water to a boil.
Prompt, aggressive measures, including temporary closure of pools, must be carried out in cases of suspected fecal contamination of recreational water. People with diarrhea should not use recreational water, and those with cryptosporidiosis should not use recreational waters for 2 weeks after symptoms resolve.
Wearing gloves and handwashing after handling diapers can prevent person-to-person spread in daycare centers and hospitals. Endoscopes and similar instruments should be disinfected between uses. Prompt antiparasitic treatment of infected children decreases oocyst shedding.
Individuals with AIDS or another immunosuppressive condition should avoid swimming in communal pools or recreational water.
In hospitalized patients, contact precautions are strictly recommended in addition to standard precautions for patients who are incontinent or who use diapers.
White AC Jr. Cryptosporidiosis (Cryptosporidium species). Bennett JE, Dolin R, Blaser MK, eds. Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2015. Chapter 284, pages 3173-83.
Checkley W, White AC Jr, Jaganath D, Arrowood MJ, Chalmers RM, Chen XM, et al. A review of the global burden, novel diagnostics, therapeutics, and vaccine targets for cryptosporidium. Lancet Infect Dis. 2015 Jan. 15 (1):85-94. [Medline].
Yoder JS, Beach MJ. Cryptosporidium surveillance and risk factors in the United States. Exp Parasitol. 2010 Jan. 124(1):31-9. [Medline].
Painter JE, Hlavsa MC, Collier SA, Xiao L, Yoder JS, Centers for Disease Control and Prevention. Cryptosporidiosis surveillance -- United States, 2011-2012. MMWR Suppl. 2015 May 1. 64 (3):1-14. [Medline].
Chalmers RM, Smith R, Elwin K, Clifton-Hadley FA, Giles M. Epidemiology of anthroponotic and zoonotic human cryptosporidiosis in England and Wales, 2004-2006. Epidemiol Infect. 2011 May. 139(5):700-12. [Medline].
Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL, et al. Foodborne illness acquired in the United States--major pathogens. Emerg Infect Dis. 2011 Jan. 17(1):7-15. [Medline]. [Full Text].
Mac Kenzie WR, Hoxie NJ, Proctor ME, Gradus MS, Blair KA, Peterson DE, et al. A massive outbreak in Milwaukee of cryptosporidium infection transmitted through the public water supply. N Engl J Med. 1994 Jul 21. 331(3):161-7. [Medline].
Chalmers RM. Waterborne outbreaks of cryptosporidiosis. Ann Ist Super Sanita. 2012. 48 (4):429-46. [Medline].
Semenza JC, Nichols G. Cryptosporidiosis surveillance and water-borne outbreaks in Europe. Euro Surveill. 2007 May 1. 12(5):E13-4. [Medline].
Cooper DL, Verlander NQ, Smith GE, Charlett A, Gerard E, Willocks L, et al. Can syndromic surveillance data detect local outbreaks of communicable disease? A model using a historical cryptosporidiosis outbreak. Epidemiol Infect. 2006 Feb. 134(1):13-20. [Medline]. [Full Text].
Fournet N, Deege MP, Urbanus AT, Nichols G, Rosner BM, Chalmers RM, et al. Simultaneous increase of Cryptosporidium infections in the Netherlands, the United Kingdom and Germany in late summer season, 2012. Euro Surveill. 2013 Jan 10. 18(2):[Medline].
Ajjampur SS, Rajendran P, Ramani S, Banerjee I, Monica B, Sankaran P, et al. Closing the diarrhoea diagnostic gap in Indian children by the application of molecular techniques. J Med Microbiol. 2008 Nov. 57:1364-8. [Medline].
Shirley DA, Moonah SN, Kotloff KL. Burden of disease from cryptosporidiosis. Curr Opin Infect Dis. 2012 Oct. 25(5):555-63. [Medline].
Nair P, Mohamed JA, DuPont HL, Figueroa JF, Carlin LG, Jiang ZD, et al. Epidemiology of cryptosporidiosis in North American travelers to Mexico. Am J Trop Med Hyg. 2008 Aug. 79(2):210-4. [Medline]. [Full Text].
O'connor RM, Shaffie R, Kang G, Ward HD. Cryptosporidiosis in patients with HIV/AIDS. AIDS. 2011 Mar 13. 25(5):549-60. [Medline].
Wang L, Zhang H, Zhao X, Zhang L, Zhang G, Guo M, et al. Zoonotic Cryptosporidium species and Enterocytozoon bieneusi genotypes in HIV-positive patients on antiretroviral therapy. J Clin Microbiol. 2013 Feb. 51(2):557-63. [Medline]. [Full Text].
Wumba R, Longo-Mbenza B, Mandina M, Odio WT, Biligui S, Sala J, et al. Intestinal parasites infections in hospitalized AIDS patients in Kinshasa, Democratic Republic of Congo. Parasite. 2010 Dec. 17(4):321-8. [Medline].
Mondal D, Haque R, Sack RB, Kirkpatrick BD, Petri WA Jr. Attribution of malnutrition to cause-specific diarrheal illness: evidence from a prospective study of preschool children in Mirpur, Dhaka, Bangladesh. Am J Trop Med Hyg. 2009 May. 80(5):824-6. [Medline]. [Full Text].
Guerrant DI, Moore SR, Lima AA, Patrick PD, Schorling JB, Guerrant RL. Association of early childhood diarrhea and cryptosporidiosis with impaired physical fitness and cognitive function four-seven years later in a poor urban community in northeast Brazil. Am J Trop Med Hyg. 1999 Nov. 61(5):707-13. [Medline].
Amadi B, Mwiya M, Musuku J, Watuka A, Sianongo S, Ayoub A, et al. Effect of nitazoxanide on morbidity and mortality in Zambian children with cryptosporidiosis: a randomised controlled trial. Lancet. 2002 Nov 2. 360(9343):1375-80. [Medline].
Vakil NB, Schwartz SM, Buggy BP, Brummitt CF, Kherellah M, Letzer DM, et al. Biliary cryptosporidiosis in HIV-infected people after the waterborne outbreak of cryptosporidiosis in Milwaukee. N Engl J Med. 1996 Jan 4. 334(1):19-23. [Medline].
Chalmers RM, Campbell BM, Crouch N, Charlett A, Davies AP. Comparison of diagnostic sensitivity and specificity of seven Cryptosporidium assays used in the UK. J Med Microbiol. 2011 Nov. 60:1598-604. [Medline].
Committee on Infectious Diseases, American Academy of Pediatrics. Cryptosporidiosis. Kimberlin DW, Brady MT, Jackson MA, Long Ss, eds. Red Book. 30th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2015. 312-18.
Rossignol JF, Kabil SM, el-Gohary Y, Younis AM. Effect of nitazoxanide in diarrhea and enteritis caused by Cryptosporidium species. Clin Gastroenterol Hepatol. 2006 Mar. 4(3):320-4. [Medline].
Rossignol JF, Ayoub A, Ayers MS. Treatment of diarrhea caused by Cryptosporidium parvum: a prospective randomized, double-blind, placebo-controlled study of Nitazoxanide. J Infect Dis. 2001 Jul 1. 184(1):103-6. [Medline].
Cabada MM, White AC Jr. Treatment of cryptosporidiosis: do we know what we think we know?. Curr Opin Infect Dis. 2010 Oct. 23(5):494-9. [Medline].
Pantenburg B, White AC Jr. Nitazoxanide. In: Grayson ML, ed. Kucer’s The Use of Antibiotics. 6th ed. London, United Kingdom: Hodder Arnold; 2010:2132-9.
Smith NH, Cron S, Valdez LM, Chappell CL, White AC Jr. Combination drug therapy for cryptosporidiosis in AIDS. J Infect Dis. 1998 Sep. 178(3):900-3. [Medline].
Masur H, Brooks JT, Benson CA, Holmes KK, Pau AK, Kaplan JE, et al. Prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Updated Guidelines from the Centers for Disease Control and Prevention, National Institutes of Health, and HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2014 May. 58 (9):1308-11. [Medline]. [Full Text].
Hicks P, Zwiener RJ, Squires J, Savell V. Azithromycin therapy for Cryptosporidium parvum infection in four children infected with human immunodeficiency virus. J Pediatr. 1996 Aug. 129(2):297-300. [Medline].
Centers for Disease Control and Prevention. Parasites – Cryptosporidium (also knows as "Crypto"). Cdc.com. Available at http://www.cdc.gov/parasites/crypto/. Accessed: April 9, 2013.
Amadi B, Mwiya M, Sianongo S, Payne L, Watuka A, Katubulushi M, et al. High dose prolonged treatment with nitazoxanide is not effective for cryptosporidiosis in HIV positive Zambian children: a randomised controlled trial. BMC Infect Dis. 2009 Dec 2. 9:195. [Medline]. [Full Text].
Cama VA, Bern C, Roberts J, Cabrera L, Sterling CR, Ortega Y, et al. Cryptosporidium species and subtypes and clinical manifestations in children, Peru. Emerg Infect Dis. 2008 Oct. 14(10):1567-74. [Medline]. [Full Text].