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Babesiosis: Treatment & Medication
Updated: Apr 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
- Suspicion of babesiosis in a patient with a history of exposure in an endemic area, tick bite, fever, chills, and fatigue is crucial.
- Peripheral blood smear or immunologic testing (see Workup) is necessary to make the diagnosis.
- If the patient is otherwise healthy and asymptomatic, no treatment is required.
- CBC with differential is important to determine the severity of infection.
- Immediately start elderly, immunocompromised, or asplenic patients on a combination treatment regimen of intravenous clindamycin and oral quinine or intravenous atovaquone and intravenous azithromycin to avoid acute renal failure.
- Intubation and mechanical ventilation may be required for patients who develop respiratory distress or failure.
Consultations
- Consult an infectious disease specialist on all babesiosis-infected patients who require hospital admission.
- Consult a hematologist for whole-blood exchange transfusion in severe cases.
Medication
Antibiotic and antimalarial therapy should begin immediately after diagnosis in symptomatic patients to reduce the level of parasitemia. The standard treatment has been clindamycin and quinine, but this regimen occasionally fails and patients report frequent side effects including tinnitus, decreased hearing, and diarrhea. Because of this, the drug regimen consisting of atovaquone and azithromycin is now the first line of treatment for mild/moderate disease and has been shown to be effective especially when clindamycin and quinine fail. For patients with severe symptoms, clindamycin and quinine are the first line of treatment.1 Parasitemia may persist despite treatment with either of the described drug regimens. In areas endemic for Lyme disease, physicians should consider treating for Lyme disease empirically.
Asymptomatic patients with positive smears and/or PCR results should have these studies repeated and a course of treatment started if parasitemia persists more than 3 months. Additionally, patients initially treated may require re-treatment if repeat smears or PCR are positive more than 3 months after initial therapy.
Partial or whole-blood exchange transfusion is indicated for patients with severe babesiosis, as demonstrated by high parasitemia (>10%); significant hemolysis; and/or renal, hepatic, or pulmonary dysfunction.
Antibiotics
Therapy should cover all likely pathogens in the context of this clinical setting.
Clindamycin (Cleocin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Administer in combination with quinine.
Adult
300-600 mg IV qid or 600 mg PO tid for 7-10 d
Pediatric
7-10 mg/kg/d IV or PO tid/qid for 7-10 d; maximum of 600 mg/dose
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Azithromycin (Zithromax)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Treats mild-to-moderate microbial infections. Administer in combination with atovaquone.
Adult
Day 1: 500 mg PO
Days 2-10: 250 mg PO
Immunocompromised patients: Higher doses of 600-1000 mg/d may be used
Pediatric
Day 1: 10 mg/kg/d PO; maximum of 500 mg/dose
Days 2-10: 5 mg/kg/d PO; maximum of 250 mg/dose
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzyme levels and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized patients, geriatric patients, or debilitated patients
Antiprotozoals
These agents may contribute to the eradication of the parasite.
Atovaquone (Mepron)
May inhibit metabolic enzymes, which, in turn, inhibit growth of microorganisms. Administer in combination with azithromycin.
Adult
750 mg PO q12h for 7 d
Pediatric
20 mg/kg q12h; maximum of 750 mg/dose
May increase zidovudine serum levels; coadministration with rifampin or rifabutin may decrease atovaquone levels; atovaquone may decrease levels of TMP-SMZ
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in elderly patients and in hepatic and renal impairment
Anti-malarials
These agents are effective in eradicating the parasite.
Quinine sulfate (Formula Q)
Inhibits growth of parasite by increasing the pH within intracellular organelles and possibly by intercalating into DNA of the parasites. Administer in combination with clindamycin.
Adult
650 mg PO tid/qid for 7-10 d
Pediatric
8 mg/kg PO tid for 7 d; maximum of 650 mg/dose
Aluminum-containing antacids may delay or decrease quinine bioavailability when administered concurrently; cimetidine increases quinine blood levels and creates the potential for toxicity; rifamycins decrease quinine concentrations by increasing hepatic clearance of quinine (effect can persist for several days after discontinuing rifamycins); concurrent administration of acetazolamide or sodium bicarbonate may increase toxicity by increasing quinine blood levels; quinine may enhance action of warfarin and other oral anticoagulants by decreasing synthesis of vitamin K–dependent clotting factors; digoxin serum concentrations may increase when digoxin administered concurrently with quinine; important to monitor digoxin levels periodically; quinidine may decrease plasma cholinesterase activity, causing a decrease in the metabolism of succinylcholine
Documented hypersensitivity; optic neuritis; tinnitus; G-6-PD deficiency; history of black water fever
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in G-6-PD deficiency and tendency to develop granulocytopenia; prolonged treatment or overdosing with quinine may cause cinchonism; quinine has quinidinelike activity, and thus can cause cardiac arrhythmias
More on Babesiosis |
| Overview: Babesiosis |
| Differential Diagnoses & Workup: Babesiosis |
 Treatment & Medication: Babesiosis |
| Follow-up: Babesiosis |
| Multimedia: Babesiosis |
| References |
| Further Reading |
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Further Reading
Clinical guidelines
Infectious Diseases Society of America practice guidelines for clinical assessment, treatment and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis. Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt L, Fish D, Dumler JS, Nadelman RB. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006 Nov 1;43(9):1089-134. PubMed
Keywords
babesiosis, Babesia species, Ixodes tick, parasitic infection, intraerythrocytic parasitic infection, tick bite, hemolytic anemia, thrombocytopenia, atypical lymphocyte formation, acute respiratory distress syndrome, ARDS, Lyme disease, Ixodes scapularis, white-tailed deer, white-footed mouse, Peromyscus leucopus, adult tick vector
