eMedicine Specialties > Pediatrics: General Medicine > Parasitology
Cryptosporidiosis: Treatment & Medication
Updated: Apr 29, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- No reliable curative treatment for cryptosporidiosis is available.17
- Fluid and electrolyte management is critical, particularly in cases with large diarrheal losses.
- Nonspecific antidiarrheal agents may provide relief.
- Octreotide, a somatostatin analogue and substance P antagonist, suppresses diarrhea in chronic cryptosporidiosis.
Surgical Care
- Biliary involvement in cryptosporidiosis requires specific interventions.
- Acalculous cholecystitis should be treated with cholecystectomy.
- Patients with sclerosing cholangitis can usually be treated by endoscopic retrograde cholangiopancreatography (ERCP), although sphincterotomy may result in temporary relief.
- In selected cases, recurrence may be prevented by placing a stent.
Consultations
- Infectious diseases specialist (for evaluation and specific treatment options)
- Gastroenterologist (particularly for hepatobiliary involvement)
- Surgeon (for cholecystectomy and T-tube drainage)
Diet
- Supportive care should include a lactose-free diet.
- Although nutrition remains important, feeding is as effective as parenteral nutrition.
- Fluids should include sodium, potassium, bicarbonate, and glucose.
Activity
- Individuals with AIDS and other conditions that cause immunosuppression may wish to avoid swimming in communal pools.
- In hospitalized patients, contact precautions are strictly recommended in addition to standard precautions for patients who are incontinent or who use diapers.
- Handwashing and wearing gloves can prevent spread in daycare centers.
- Travelers visiting developing countries can bring drinking water to boil before consuming.
Medication
Supportive therapy is the key component in the management of cryptosporidiosis. Replacement of fluids and electrolytes is the critically important first step in the management of this diarrheal illness. Oral rehydration is the preferred mode, but severely ill patients may require parenteral fluids. Mature epithelial cells at the tips of the villi are preferentially lost; hence, enzymes expressed on these cells (including lactase) are lost. These losses lead to secondary lactose intolerance. Therefore, supportive care should include a lactose-free diet.
Pharmaceutical treatment is not satisfactory. Many agents have been tried with variable and limited success.
In December 2002, the US Food and Drug administration (FDA) approved nitazoxanide (Alinia) as an oral suspension to treat children with diarrhea caused by Cryptosporidium.18,7 A short, 3-day course of the suspension (100 mg/5 mL) was approved in children aged 1-11 years. In clinical trials, the agent significantly reduced the duration of diarrhea caused by Cryptosporidium infections. It also reduced the rate of death in malnourished children in Africa with Cryptosporidium infection. The most common adverse effects reported were abdominal pain, diarrhea, vomiting, and headache; adverse effects were not significantly different from those reported with a placebo.
Orally administered human serum immunoglobulin or bovine colostrum has been used successfully in several anecdotal reports.
In patients with AIDS, antiretroviral treatment has been associated with improvement, possibly because of general improvement of immune function.13,18,19 Combination therapy with paromomycin and azithromycin for 4 weeks followed by paromomycin monotherapy for 8 wk has been successfully used in adult patients with AIDS. Clarithromycin has also shown activity in vitro and in animal studies, but only limited data on treatment of human cryptosporidiosis is available.
Antidiarrheal agents
These are used to adjunctly treat diarrhea with rehydration therapy to correct fluid and electrolyte depletion. They may provide temporary relief for some patients. Octreotide (Sandostatin) may help but is expensive.
Bismuth subsalicylate (Pepto-Bismol)
Exerts antisecretory and antimicrobial effects to control diarrhea.
Adult
524 mg (2 chewable tabs or 30 mL regular strength liquid) PO q30 min to q1h prn; not to exceed 8 doses/d
Pediatric
<3 years: Not established
3-5 years: 87 mg (5 mL regular-strength liquid) PO q30min to q1h prn; not to exceed 700 mg/d (8 doses/d)
6-9 years: 175 mg (10 mL regular-strength liquid) PO q30min to q1h prn; not to exceed 1400 mg/d (8 doses/d)
10-12 years: 262 mg (15 mL regular-strength liquid) PO q30min to q1h prn; not to exceed 2100 mg/d (8 doses/d)
>12 years: Administer as in adults
Coadministration with anticoagulants may increase risk of bleeding; may increase toxicity of aspirin and hypoglycemics; decreases effects of tetracyclines and uricosurics
Documented hypersensitivity; because of association of aspirin with Reye syndrome, do not use in children (<16 y) with flu
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause temporary and harmless darkening of tongue and/or black stool; alcohol consumption may cause abdominal cramps, nausea, and vomiting
Attapulgite (Kaopectate, Diasorb)
Adsorbent and protectant that controls diarrhea.
Adult
1200-1500 mg PO after each loose bowel movement; not to exceed 7 doses/d or 9 g/d
Pediatric
<3 years: Not recommended
3-5 years: 150 mg PO after each loose bowel movement; not to exceed 7 doses/d
6-12 years: 300 mg PO after each loose bowel movement; not to exceed 7 doses/d
>12 years: Administer as in adults
Decreases absorption of digoxin, clindamycin, tetracyclines, and penicillamine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients >60 y; avoid in presence of high fever; at high doses, may cause constipation
Octreotide (Sandostatin)
Primarily acts on somatostatin receptor subtypes II and V. Inhibits GH secretion and has multitude of other endocrine and nonendocrine effects, including inhibition of glucagon, VIP, and GI peptides.
Adult
Not established, limited data suggest 100-300 mcg IV/SC q8h
Pediatric
Not established, limited data suggest 1-10 mcg IV/SC q12h; initiate at low dose, may increase by increments of 0.3 μ g/kg/dose q3d; growth hormone suppression with long-term use
May reduce effects of cyclosporine; patients on insulin, oral hypoglycemics, beta-blockers, and calcium channel blockers may need dosage adjustments
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse effects primarily related to altered GI motility and include nausea, abdominal pain, diarrhea, and increased incidence of gallstones and biliary sludge; because of alteration in counterregulatory hormones (eg, insulin, glucagon, GH), hypoglycemia or hyperglycemia may be observed; bradycardia, cardiac conduction abnormalities, and arrhythmias have been reported; because of inhibition of TSH secretion, hypothyroidism may occur; caution with renal impairment; cholelithiasis may occur; growth hormone suppression with long-term use
Antimicrobial agents
A 3-day course of nitazoxanide oral suspension has been approved by the FDA for treatment of children older than 12 months and adults with diarrhea due to cryptosporidiosis. Paromomycin alone or with azithromycin is minimally effective. No specific treatment is necessary for patients who are immunocompetent. In patients with HIV infection, improvement in CD4 cell count with antiretroviral therapy can improve the course of disease.
Nitazoxanide (Alinia)
Inhibits growth of C parvum sporozoites and oocysts and G lamblia trophozoites. Elicits antiprotozoal activity by interfering with pyruvate-ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer reaction, which is essential to anaerobic energy metabolism. Available as a 20-mg/mL oral susp.
Adult
500 mg PO bid for 3 d
Pediatric
<1 year: Not established
1-3 years: 100 mg (5 mL) PO q12h for 3 d with food
4-11 years: 200 mg (10 mL) PO q12h for 3 d with food
>11 years: Administer as in adults
Tizoxanide (nitazoxanide metabolite) is >99.9% bound to plasma protein and may potentially increase toxicity of other highly plasma protein–bound drugs
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause abdominal pain, diarrhea, vomiting, or headache; administer with food; caution when coadministered with other highly plasma protein–bound drugs with narrow therapeutic indices
Paromomycin (Humatin)
A poorly absorbed aminoglycoside antibiotic that has been used in patients who have AIDS and cryptosporidiosis. It has been reported to cause symptomatic improvement and possible parasite eradication in a small series of patients.
Adult
500-750 mg PO tid/qid or 1 g PO bid
Pediatric
25-35 mg/kg/d PO divided tid
Nephrotoxic potential may increase with concurrent administration of other aminoglycosides, penicillins, cephalosporins, amphotericin B, and loop diuretics
Documented hypersensitivity; intestinal obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; do not use for long-term therapy because of narrow therapeutic index and toxic hazards associated with extended administration
Azithromycin (Zithromax)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
500 mg PO qd
Pediatric
Not established; limited data from case reports only
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
May increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized patients, elderly patients, or debilitated patients
More on Cryptosporidiosis |
| Overview: Cryptosporidiosis |
| Differential Diagnoses & Workup: Cryptosporidiosis |
 Treatment & Medication: Cryptosporidiosis |
| Follow-up: Cryptosporidiosis |
| Multimedia: Cryptosporidiosis |
| References |
| « Previous Page | Next Page » |
References
Meinhardt PL, Casemore DP, Miller KB. Epidemiologic aspects of human cryptosporidiosis and the role of waterborne transmission. Epidemiol Rev. 1996;18(2):118-36. [Medline].
Fayer R, Morgan U, Upton SJ. Epidemiology of Cryptosporidium: Transmission,detection and identification. Int J Parasitol. 2000;30:1305-1322.
Flynn PM. Cryptosporidium parvum. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatrics. New York, NY: Churchill Livingstone; 1997.
White C Jr. Cryptosporidiosis. In: Mandell GL, Bennett JE, Doilin R. Principles and practice of Infectious Diseases. Vol 2. 6th. Philadelphia, Pennsylvania: Elsivier Churchill Livingstone; 2005:280.
Huang DB, Chappell C, Okhuysen PC. Cryptosporidiosis in children. Semin pediatr Infect Dis. Oct, 2004;15 (4):253-259. [Medline].
CDC. Classification system for human T-lymphotropic virus type III/lymphadenopathy-associated virus infections. MMWR Morb Mortal Wkly Rep. May 23 1986;35(20):334-9. [Medline].
Committee on Infectious Diseases, American Academy of Pediatrics. Cryptosporidiosis. In: Pickering LK, Baker CJ, Long S, McMillan JA. Red book. 27th. Elk Grove Village, IL: AAP; 2006:270-272.
MacKenzie WR, Schell WL, Blair KA. Massive outbreak of waterborne Cryptosporidium infection in Milwaukee, Wisconsin. Clin Infect Dis. Jul, 1995;21 (1):57-62. [Medline].
Cryptosporidiosis surveillance--United States, 2003-2005 [database online]. Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC, Atlanta, GA 30333, USA. jey9@cdc.gov: Yoder JS, Beach MJ; Centers for Disease Control and Prevention (CDC).; 2007 Sep 7.
Semenza JC, Nichols G. Cryptosporidiosis surveillance and water-borne outbreaks in Europe. Euro Surveill. May 2007;1;12(5):E13-4. [Medline].
Cooper DL, Verlander NQ, Smith GE, et al. Can syndromic surveillance data detect local outbreaks of communicable disease? A model using a historical cryptosporidiosis outbreak. Epidemiol Infect. Feb 2006;134(1):13-20. [Medline].
Navin TR, Hardy AM. Cryptosporidiosis in patients with AIDS. J Infect Dis. Jan 1987;155(1):150. [Medline].
Abubakar I, Aliyu SH, Arumugam C, Usman NK, Hunter PR. Treatment of cryptosporidiosis in immunocompromised individuals: systematic review and meta-analysis. Br J Clin Pharmacol. Apr 2007;63(4):387-93. [Medline]. [Full Text].
Wolska-Kusnierz B, Bajer A, Caccio S, Heropolitanska-Pliszka E, Bernatowska E, Socha P, et al. Cryptosporidium infection in patients with primary immunodeficiencies. J Pediatr Gastroenterol Nutr. Oct 2007;45(4):458-64. [Medline].
Cello JP. Acquired immunodeficiency syndrome cholangiopathy: spectrum of disease. Am J Med. May 1989;86(5):539-46. [Medline].
Weintraub JM. Improving cryptosporidium testing methods: a public health perspective. J Water Health. 2006;4 Suppl 1:23-6. [Medline].
Soave R. Treatment strategies for cryptosporidiosis. Ann N Y Acad Sci. 1990;616:442-51. [Medline].
Fox LM, Saravolatz LD. Nitazoxanide: a new thiazolide antiparasitic agent. Clin Infect Dis. 2005;40 (8)::1173-80. [Medline].
Smith NH, Cron S, Valdez LM, et al. Combination drug therapy for cryptosporidiosis in AIDS. J Infect Dis. Sep 1998;178(3):900-3. [Medline].
Juranek DD. Cryptosporidiosis: sources of infection and guidelines for prevention. Clin Infect Dis. Aug 1995;21 Suppl 1:S57-61. [Medline].
Further Reading
Keywords
cryptosporidiosis, Cryptosporidium, Cryptosporidium parvum, C parvum, Cryptosporidium hominis, C hominis, diarrhea, oocysts, acquired immunodeficiency syndrome, AIDS, Plasmodium, Cryptosporidium canis, waterborne infection, traveler's diarrhea, diarrhea, villous atrophy, malabsorption, steatorrhea, foodborne diarrhea, hepatobiliary disease, respiratory disease, jaundice, nausea, vomiting, croup, respiratory infection, human immunodeficiency virus, HIV, acalculous cholecystitis, sclerosing cholangitis, pancreatitis, ascites, icterus, reactive arthritis, diabetes mellitus, cytomegalovirus, CMV, Enterobacter cloacae, microsporidia, Pneumocystis carinii
