Gastroenteritis - Parasitic (1 of 13)
Transcript of Gastroenteritis - Parasitic (1 of 13)
B1
B RECOMMENDED THERAPY FOR PROTOZOAL PARASITES
PathogenDrug
Preferred Agents Alternative AgentsCryptosporidium sp Nitazoxanide -Entamoeba histolytica (Amoebiasis)• Asymptomatic cyst passer
Paromomycin Iodoquinol or Diloxanide furoate
E histolytica (Amoebiasis)• Mild-moderate intestinal disease
Metronidazole or Tinidazole -
E histolytica (Amoebiasis)• Severe intestinal disease or
liver abscess
Metronidazole or Tinidazole -
Giardia lamblia (Giardiasis) In most immunocompetent patients, giardiasis is self-limiting & does not require treatment. In nonendemic areas, asymptomatic carriers of giardiasis are treatedMetronidazole, Nitazoxanide or Tinidazole
Furazolidone, Paromomycin or Quinacrine
Gastroenteritis - Parasitic (1 of 13)
Yes
No
Protozoal infectionHelminthic infection
1Patient presents w/ signs & symptoms
suggestive of gastroenteritis
2DIAGNOSIS
Do history & lab results support parasitic
infection?
Protozoal or helminthic
infection?
A Non-pharmacological therapy• Rehydration & nutrition
- Oral rehydration solution (ORS)• Education about preventive measures
PHARMACOTHERAPY FOR HELMINTHIC INFECTIONSSee next page
ALTERNATIVE DIAGNOSIS• Consider viral or bacterial
gastroenteritis- Please see Gastroenteritis - Viral
or Gastroenteritis - Bacterial disease management charts for further information
Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.
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Gastroenteritis - Parasitic (2 of 13)
Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.
HELMINTHIC INFECTIONS
C RECOMMENDED THERAPY FOR HELMINTHS
PathogenDrug
Preferred Agents Alternative AgentsCestodes (Tapeworms) Taenia saginata (beef tapeworm), Taenia solium (pork tapeworm), Taenia asiatica (Asian tapeworm)
Praziquantel Niclosamide
Diphyllobothrium caninum, Diphyllobothrium latum (fi sh or broad tapeworm)
Praziquantel Niclosamide
Hymenolepis nana (dwarf tapeworm) Praziquantel Niclosamide or NitazoxanideNematodes (Roundworms) Ascaris lumbricoides (Ascariasis) Albendazole, Ivermectin or
MebendazoleNitazoxanide
Ancylostoma duodenale, Necator americanus (Ancylostomiasis)(Hookworms)
Albendazole, Mebendazole or Pyrantel pamoate
-
Capillaria philippinensis (Capillariasis) Mebendazole AlbendazoleEnterobius vermicularis (Pinworm) Pyrantel pamoate,
Albendazole or Mebendazole -
Strongyloides stercoralis(Strongyloidiasis)
Ivermectin Albendazole or� iabendazole
Trichuris trichiura (Whipworm) Mebendazole Albendazole or IvermectinTrematodes (Flukes)Clonorchis sinensis (Oriental liver fl uke) Praziquantel AlbendazoleFasciola hepatica (Fascioliasis) Triclabendazole Bithionol or NitazoxanideFasciolopsis buski, Heterophyes heterophyes, Metagonimus yokogawai (Intestinal fl ukes)
Praziquantel -
Opisthorchis viverrini (Southeast Asian liver fl uke)
Praziquantel Albendazole
Paragonimus westermani (Lung fl ukes) Praziquantel Triclabendazole or BithionolSchistosoma haematobium Praziquantel -Schistosoma japonicum Praziquantel -Schistosoma mansoni Praziquantel Oxamniquine
A Non-pharmacological therapy• Rehydration & nutrition
- Oral rehydration solution (ORS)• Education about preventive measures
FOLLOWUP• Repeat lab exams to document eradication of parasite, if necessary
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Gastroenteritis - Parasitic (3 of 13)
1 GASTROINTESTINAL PARASITIC INFECTIONS
• Parasites causing gastrointestinal symptoms may be transmitted to humans via the fecal-oral route by food or water ingestion, or by skin penetration
Parasites According to their Mode of Transmission• Soil-transmitted helminths: Ascaris lumbricoides, Ancylostoma duodenale, Necator americanus, Strongyloides
stercoralis, Trichuris trichiura• Food-borne trematodes: Clonorchis sinensis, Opisthorchis viverrini, Fasciola hepatica, Paragonimus sp.• Water-borne parasites: Schistosoma haematobium/japonicum/mansoni, Cryptosporidium sp., Giardia lamblia,
Entamoeba histolyticaSigns & Symptoms• Frequently, patients w/ gastrointestinal parasitic infections do not have any signs & symptoms that are specifi c
for parasitic infections (eg fever, malaise, fatigue, sweating, weight loss, anorexia, edema, pruritus)• Some patients may be asymptomatic• Gastrointestinal symptoms, if present, include diarrhea, abdominal pain, dysentery, fl atulence, jaundice, rectal
prolapse, dyspepsia, malabsorption, vomiting & biliary colic• Extraintestinal infection can also occur & may give rise to symptoms eg headache, seizures, cough, dyspnea,
hemoptysis, wheezing, vulvovaginitis, dysuria, hematuria, skin rashes, pruritus, arthralgia, anemia, fatigue & claudication
2 DIAGNOSIS
Clinical History• Attempt to elicit a history of possible exposure, especially for helminthic infections (eg eating undercooked
meat, ingestion of undercooked or raw fi sh, swimming in fresh water where certain parasites may be endemic, walking barefoot)
• Knowledge of the geographic distribution of parasites is helpful in the diagnosis Host Susceptibility Factors in Gastrointestinal Parasitic Infections• Nutritional status• Immunosuppressive drugs• Age (newborn)• Intercurrent disease• Presence of a malignancyPhysical Exam• Findings are nonspecifi cLab TestsMicroscopic Exam of Stools• Fundamental to the diagnosis of all gastrointestinal parasitic infections
- A minimum of 3 stool specimens, examined by trained personnel using a concentration & a permanent stain technique, should be used
- � e stool exam is used to detect protozoan cysts & trophozoites, helminth ova, proglottids, larvae or adult worms
- A fecal sample must be mixed well before examination because eggs are never uniformly distributed in fecesOther Lab Tests• � e following are other tests that may be used to document a parasitic infection, as necessary
- Duodenal aspirate - Biopsy- String capsule test- Immunofl uorescent antibody test- Enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR)- Cellophane tape test- Barium studies
• Anemia & eosinophilia may be seen on the complete blood count (CBC)- Eosinophilia may be seen especially w/ helminthic infections - Anemia may be seen especially in severe cases of hookworm infection
• Sudan stain for malabsorption • Liver biopsy, abdominal imaging studies (eg abdominal ultrasound, computerized axial tomography scan) may
be considered as supportive evidence in patients w/ suspected Fasciola hepatica infection
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Gastroenteritis - Parasitic (4 of 13)
Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.
A NON-PHARMACOLOGICAL THERAPYRehydration & NutritionAdequate Hydration & Nutrition• Patients w/ parasitic infections frequently suff er from malabsorption, vomiting & diarrhea, resulting in
malnutrition• Ensure that patient’s nutritional & hydration status are maintained at acceptable levels Replacement of Fluid & Electrolyte Losses• Vomiting & diarrhea result in fl uid & electrolyte losses, mainly sodium & potassium, & these patients should
be assessed for signs of dehydration• May initiate oral rehydration therapy using oral rehydration solution (ORS) for patients w/ indications for fl uid
& electrolyte replacement• ORS concentration recommended by the World Health Organization (WHO): 75 mEq/L sodium, 75 mmol/L
glucose w/ total osmolarity of 245 mOsm/L, or ½ teaspoon of salt & 6 teaspoons of sugar in 1 L of water • � e WHO-recommended amount to be given for each fl uid loss based on weight & age are as follows:
Weight Age Amount (within the fi rst 4 hours)
<5 kg (11 lb) <4 months 200400 mL5-7.9 kg (11 lb - 17 lb, 7 oz) 4-11 months 200400 mL
8-10.9 kg (17 lb, 10 oz - 24 lb) 12-23 months 600800 mL11-15.9 kg (24 lb, 4 oz - 35 lb) 2-4 years 8001200 mL
16-29.9 kg (35 lb, 4 oz - 65 lb, 15 oz) 5-14 years 12002200 mL30 kg (66 lb, 2 oz) or more ≥15 years 22004000 mL
Blood Transfusion & Treatment w/ Ferrous sulfate• � ese measures may be necessary in hookworm infections which may cause severe anemiaEducation About Preventive Measures• Health education regarding personal hygiene, routes of transmission & prevention of transmission• Handwashing to interrupt the fecal-oral or urinary-oral route of transmission of many parasites• Good food hygiene (eg washing all vegetables & fruit before consumption) to interrupt fecal-oral
transmission- Kitchen utensils must be washed frequently- Meat & fi sh must be properly cooked- Wash fruits & vegetables in treated water
• Refrain from drinking untreated water or using ice from untreated water sources• Use of footwear to inhibit the soil-to-skin route of infection • When going swimming, avoid swallowing pool water & check the pool’s pH & chlorine level, is possible• Targeted chemotherapy may prevent infections, like treating family contacts of a patient w/ certain parasitic
infections (eg enterobiasis)• Proper disposal of sewage & wastewater to avoid contamination of food crops or water supplies by fecal
material• Compost of human waste to kill infective forms of parasites© M
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Gastroenteritis - Parasitic (5 of 13)
Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.
B PHARMACOLOGICAL THERAPY FOR PROTOZOAL INFECTIONSDrugs for Treatment of Amoebiasis• Treatment w/ a tissue-active amoebicide should always be followed by a luminal cysticidal agentTissue Amoebicides• Eg Metronidazole, Ornidazole, Tinidazole• � ese agents are eff ective in treating invasive amoebiasis but are less eff ective in treating organisms in the
bowel lumenLuminal Amoebicides• Eg Diloxanide furoate, Iodoquinol, Paromomycin (preferred)• � ese agents are eff ective in treating organisms in the bowel lumen
- May be used in patients w/ asymptomatic E histolytica infection• Recommended for asymptomatic cyst passers
- To avoid the risk of developing invasive disease- To prevent secondary spread
• When asymptomatic cyst carriage persists after treatment for amoebic dysentery or liver abscess, further treatment w/ a luminal amoebicide is mandatory, otherwise relapse is frequent
• Paromomycin- Drug of choice for asymptomatic intestinal infection w/ E histolytica- Temporarily eliminates diarrhea in human immunodeficiency virus (HIV) patients who have
cryptosporidiosis- May also be used in treatment of cryptosporidiosis & giardiasis
Other Antiprotozoal Drugs• Eg Furazolidone, Nitazoxanide, QuinacrineFurazolidone• Used for the treatment of giardiasis• Furazolidone is as eff ective as Metronidazole in the treatment of giardiasisNitazoxanide• Treatment of choice for giardiasis & cryptosporidium• Alternative therapy against F hepatica
C PHARMACOLOGICAL THERAPY FOR HELMINTHIC INFECTIONSAnthelminthicsAlbendazole• Has an exceptionally broad-spectrum of antiparasitic activity • Widely used for intestinal nematode infections
- Also eff ective against certain hookworms & roundworms• Improved gastrointestinal tract absorption w/ intake of fatty mealBithionol• Alternative agent for F hepatica when Triclabendazole is unavailable or contraindicated• Release of worm antigens may cause reactions (eg urticaria, photosensitivity reactions & gastrointestinal
symptoms)Ivermectin• First-line therapy against S stercoralis, except in patients w/ Loa loa infection, &/or <15 kg body weightMebendazole• Widely used for treatment of intestinal nematodes• Poorly absorbed from the GI tract, resulting in a low frequency of side eff ectsOxantel pamoate• An analogue of Pyrantel, used in combination w/ Albendazole or Ivermectin as an alternative treatment option
for T trichiuraPyrantel pamoate• Used for the treatment of intestinal nematodes© M
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Gastroenteritis - Parasitic (6 of 13)
Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.
C PHARMACOLOGICAL THERAPY FOR HELMINTHIC INFECTIONS (CONT'D)Anthelminthics (Cont'd)Praziquantel• Drug of choice for liver fl ukes (eg Opisthorchis viverrini, Clonorchis sinensis), intestinal fl ukes, & adult & larval
form of cestodes • Highly eff ective against all Schistosoma sp that infect humans• Combination therapy w/ Albendazole or Mebendazole is used for schistosomiasis & soil-transmitted
helminthiasis• Drug resistance is a possibility, especially in countries practicing mass chemotherapy as a control measure• Release of worm antigens may elicit responses in the patient (eg N/V, abdominal pain, dizziness, headache,
lassitude); use w/ caution in patients w/ history of epilepsy� iabendazole• Active against many intestinal adult nematodes & larval forms in tissues• High frequency of untoward eff ects & the availability of alternative agents have limited its usefulnessTriclabendazole• Treatment of choice for patients w/ F hepatica infection• Not routinely recommended for children ≤4 years of age
ADJUNCTIVE THERAPY• Antiemetic agents (eg Ondansetron) may be used in children >4 years of age to decrease vomiting or help
avoid the need for IV fl uid, but may increase episodes of diarrhea • Zinc supplementation given during an episode of diarrhea may decrease the duration & severity of diarrheal
illness, & reduce the incidence of diarrhea in the next 2-3 months- For patients up to 6 months, may give 10 mg/day PO x 10-14 days- Patients ≥6 months, may give 20 mg/day PO x 10-14 days
• Probiotics have been shown to reduce the intensity & duration of acute infectious diarrhea in children- May be used in rotavirus gastroenteritis - Eg Lactobacillus spp, Saccharomyces boulardii, Bifi dobacterium spp
• Racecadotril, an antisecretory agent, may be used as an adjunctive therapy in acute diarrhea- Studies showed decreased diarrhea duration & reduced stool output following administration of Racecadotril
in children w/ acute diarrhea• Bovine colostrum contains antimicrobial peptides (lactoferrin, lactoperoxidase), immune-regulating &
infl ammatory cytokines, & growth factors that may help provide passive immunity by enhancing diff erent immune functions (eg phagocytosis, antigen presentation, antimicrobial activity via antigen chelation, infl ammation control) in the gastrointestinal tract - Studies showed that bovine colostrum improved clinical symptoms (eg reduced stool frequency, reduced
occurrence & duration of diarrhea) in children w/ infectious diarrhea- Clinical benefi t in the prevention & management of infectious diarrhea is currently being determined in
clinical trials• Hematinics for anemia may help restore hemoglobin level• Surgical intervention may be considered in patients w/ obstruction, massive GI bleeding, perforated colon,
toxic megacolon• Human milk, gelatin tannate & other probiotics are being studied to conclude their use in the management of
gastroenteritis © MIM
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Gastroenteritis - Parasitic (7 of 13)
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
Dosage Guidelines
ANTIAMOEBICS
Drug Dosage Remarks
Diiodohydroxy-quinoline (Iodoquinol)
E histolytica (asymptomatic cyst passer):>30 mth: 5-10 mg/kg/day PO divided 6-8 hrly x 20 days
Adverse Reactions• GI eff ects (abdominal cramps, N/V, diarrhea); Eff ects
related to iodine content (pruritus ani, skin eruptions, enlargement of the thyroid gland); Neurotoxicity
• Optic nerve damage or infl ammation & peripheral neuropathy may occur w/ prolonged administration at high doses
Special Instructions• Contraindicated in patients w/ known
hypersensitivity to iodine or halogenated hydroxyquinolines, those w/ pre-existing optic neuropathy, hepatic or renal impairment; hyperthyroidism, enterohepatic acrodermatitis
• Use w/ caution in infants, children and patients w/ thyroid disease or neurological disorders
Diloxanide (Diloxanide furoate)
E histolytica (asymptomatic cyst passer):>25 kg: 20 mg/kg/day PO divided 8 hrly x 10 daysMay be repeated if necessary
Adverse Reactions• GI eff ects (fl atulence, N/V, diarrhea);
Dermatologic eff ects (pruritus, urticaria); Other eff ect (anorexia)
Mepacrine (Quinacrine)
Giardiasis:2 mg/kg/dose PO 8 hrly x 5-7 daysMax dose: 300 mg/day
Adverse Reactions• CNS eff ects (dizziness, headache, convulsions); GI
eff ects (N/V, hepatotoxicity); Dermatologic eff ects (during long administration or after large doses: reversible yellow discoloration of skin, conjunctiva, urine; blue/black discoloration of palate & nails); Other eff ects (ocular toxicity, aplastic anemia)
Special Instructions• Avoid use in patients w/ psoriasis, hepatic disease,
porphyria, psychosis
Metronidazole Amoebic intestinal/hepatic disease: 35-50 mg/kg/day PO divided 8 hrly x 5-10 days
Adverse Reactions• GI eff ects (N/V, metallic taste, diarrhea,
constipation); CNS eff ects (weakness, dizziness, headache, mood changes); Other eff ects (Candidal infection, anorexia, darkening of urine)
• Hematologic & hepatic eff ects have occurred; Rarely hypersensitivity reactions
• High dose or prolonged use has caused peripheral neuropathy & epileptiform seizures
Special Instructions• Use w/ caution in patients w/ hepatic impairment,
CNS disease, blood dyscrasias• If given >10 days recommend monitoring CBC &
clinical monitoring for CNS eff ects• Drinking alcoholic beverage is not advisable during
therapy
Giardiasis:15 mg/kg/day PO divided 8 hrly x 5-7 days© M
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Gastroenteritis - Parasitic (8 of 13)
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
Dosage Guidelines
ANTIAMOEBICS (CONT’D)
Drug Dosage Remarks
Nitazoxanide Giardiasis:1-3 yr: 100 mg PO 12 hrly x 3 days 4-12 yr: 200 mg PO 12 hrly x 3 days≥12 yr: 500 mg PO12 hrly x 3 days
Adverse Eff ects:• GI eff ects (abdominal pain, diarrhea, N/V); CNS
eff ect (headache)Special Precautions:• Use w/ caution in patients w/ diabetes, renal,
hepatic or biliary diseaseParomomycin Amoebic intestinal disease:
25-35 mg/kg/day PO divided 8 hrly x 5-10 days May be repeated after 2 wk
Adverse Reactions• CNS eff ects (headache, vertigo); Hypersensitivity
reactions (rashes, pruritus, drug fever, anaphylaxis); GI eff ects (N/V, abdominal cramps, heartburn, prolonged oral therapy may produce malabsorption syndrome w/ severe steatorrhea & diarrhea); Ototoxicity; May have potential nephrotoxicity & neuromuscular blocking eff ects
Special Instructions• Use w/ caution in patients w/ impaired GI
motility, renal or neuromuscular disorders
Cryptosporidiosis:25-35 mg/kg/day PO 8 hrly x 5-10 daysGiardiasis:25-35 mg/kg/day PO divided 8 hrly x 7 daysTapeworm (T saginata, T solium, D latum):11 mg/kg PO every 15 min x 4 doses
Secnidazole Amoebic intestinal disease:30 mg/kg PO single dose or in 2 divided doses within 4 hr x 1 day or25 mg/kg/day PO x 3 days
Adverse Reactions• GI eff ects (N/V, metallic taste, diarrhea,
constipation); CNS eff ects (weakness, dizziness, headache, mood changes); Other eff ects (anorexia, darkening of urine)
• Hematologic & hepatic eff ects have occurred; Rarely hypersensitivity reactions
• High dose or prolonged use has caused peripheral neuropathy & epileptiform seizures
Special Instructions• Use w/ caution in patients w/ hepatic
impairment, CNS disease, blood dyscrasias• If given >10 days recommend monitoring CBC
& clinical monitoring for CNS eff ects
Amoebic hepatic disease:30 mg/kg/day PO single dose or divided doses x 5 days
Giardiasis:30 mg/kg PO single dose
Tinidazole Amoebic intestinal disease: > 3 yr: 50-60 mg/kg/day PO once daily x 3 daysMax dose: 2 g/day
Adverse Reactions• GI eff ects (N/V, metallic taste, diarrhea,
constipation); CNS eff ects (weakness, dizziness, headache, mood changes); Other eff ects (Candidal infection, anorexia, darkening of urine)
• Hematologic & hepatic eff ects have occurred; Rarely hypersensitivity reactions
• High dose or prolonged use has caused peripheral neuropathy & epileptiform seizures
Special Instructions• Use w/ caution in patients w/ hepatic
impairment, CNS disease, blood dyscrasias• If given >10 days recommend monitoring CBC
& clinical monitoring for CNS eff ects• Use w/ caution in patients ≤3 yr of age since
safety & effi cacy have not been established
Amoebic hepatic disease:> 3 yr: 50-60 mg/kg/day PO once daily x 5 daysMax dose: 2 g/day
Giardiasis: > 3 yr: 50-75 mg/kg PO single doseMay be repeated once, if necessaryMax dose: 2 g/day© M
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Gastroenteritis - Parasitic (9 of 13)
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
Dosage Guidelines
ANTHELMINTICS
Drug Dosage Remarks
Albendazole Ascariasis:<2 yr: 200 mg PO single dose >2 yr: 400 mg PO single dose
Adverse Reactions • GI eff ects (abdominal pain, N/V, elevated liver
enzymes); CNS eff ects (headache, dizziness); Hematologic eff ect (leukopenia); Dermatologic eff ect (alopecia)
Special Instructions • Use w/ caution in patients w/ hepatic
impairment, women of childbearing age • Pregnancy should be avoided at least 1 month
of therapy completion
C sinensis:>2 yr: 400 mg PO 12 hrly x 3 days Capillariasis:>2 yr: 400 mg/day PO x 10 days Enterobiasis:<2 yr: 200 mg PO single dose≥2 yr: 400 mg PO single doseMay be repeated in 2-3 wk for heavy infectionGiardiasis:2-12 yr: 400 mg PO 24 hrly x 5 days Hookworms:<2 yr: 200 mg PO single dose >2 yr: 400 mg PO single dose O viverrini:>2 yr: 400 mg PO 12 hrly x 3 days Strongyloidiasis:<2 yr: 200 mg PO single dose x 3 days>2 yr: 400 mg PO single dose x 3 daysT trichiura:<2 yr: 200 mg PO single dose >2 yr: 400 mg PO single dose Tapeworm (T saginata, T solium):>2 yr: 400 mg PO 24 hrly x 3 days
Bithionol F hepatica:30-50 mg/kg PO on alternate days for a total of 10-15 dosesP westermani:30-50 mg/kg PO on alternate days x 10 -15 doses
Adverse Reactions• GI eff ects (anorexia, N/V, abdominal
discomfort, diarrhea, salivation); CNS eff ects (dizziness, headache); Dermatologic eff ect (skin rashes)
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Gastroenteritis - Parasitic (10 of 13)
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
Dosage Guidelines
ANTHELMINTICS (CONT’D)
Drug Dosage Remarks
Ivermectin Ascariasis:≥15 kg: 150-200 mcg/kg PO as a single doseStrongyloidiasis:15-24 kg: 3 mg PO 24 hrly25-35 kg: 6 mg PO 24 hrly36-50 kg: 9 mg PO 24 hrly51-65 kg: 12 mg PO 24 hrly66-79 kg: 15 mg PO 24 hrly≥80 kg: 200 mcg/kg/day PO 24 hrly x 2 days
Adverse Reactions• CNS eff ect (headache, arthralgia, myalgia); Ocular
eff ect (mild ocular irritation); Dermatologic eff ect (pruritus); Other eff ect (Fever, edema, lymphadenopathy)
Special Instructions• Supervision after administration; may need to
monitor for adverse reactions especially after repeated doses
• Use w/ caution in patients <2 yr of age or <15 kg since blood brain barrier may be less developed than in older patients
Mebendazole Ascariasis:100 mg daily PO 12 hrly x 3 days or>2 yr: 500 mg PO single dose
Adverse Reactions• GI eff ects (abdominal pain, diarrhea, N/V); CNS
eff ects (headache, dizziness); Dermatologic eff ects (alopecia, rash); Other eff ects (elevated liver enzymes, bone marrow depression, allergic reactions)
Special Instructions• Monitor CBC & liver function during prolonged
treatment• Patients <2 yr of age are relative contraindications
since safety has not been established
Capillariasis:>2 yr: 200 mg PO 12 hrly x 20 daysEnterobiasis:>2 yr: 500 mg PO single dose May repeat if necessary in 2-3 wkHookworms:100 mg PO 12 hrly x 3 days or>2 yr: 500 mg PO single doseT trichiura:100 mg daily PO 12 hrly x 3 days or>2 yr: 500 mg PO single dose x 3 days
Niclosamide Tapeworms (T saginata, T solium, D caninum & D latum):>8 yr: 1 g PO 12 hrly2-8 yr: 500 mg PO 12 hrly<2 yr: 250 mg PO 12 hrly
Adverse Reactions• Mild GI symptoms, CNS eff ect (lightheadedness);
Dermatologic eff ects (pruritus, rarely, rash)
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Gastroenteritis - Parasitic (11 of 13)
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
Dosage Guidelines
ANTHELMINTICS (CONT’D)
Drug Dosage Remarks
Oxantel Whipworm (T trichiura):10-20 mg/kg PO single doseW/ Pyrantel: 10-20 mg/kg PO single dose
Adverse Reactions• GI eff ects (abdominal pain, GI disturbances,
diarrhea); CNS eff ect (headache, dizziness, insomnia, drowsiness); Other eff ects (anorexia, rash)
Special Instructions• Use w/ caution in patients w/ preexisting hepatic
dysfunction
Enterobiasis, Hookworms, T orientalis:W/ Pyrantel: 10-20 mg/kg PO single dose
Praziquantel C sinensis:25 mg/kg PO 8 hrly x 1-3 days or40 mg/kg PO single dose
Adverse Reactions• GI eff ects (N/V, abdominal discomfort, anorexia,
diarrhea); CNS eff ects (drowsiness, dizziness, headache, malaise); Hypersensitivity reactions (fever, urticaria, skin rashes, eosinophilia)
Special Instructions• Do not use in patients w/ ocular cysticercosis
because of risk of severe eye damage resulting from destruction of the parasite
• Use w/ caution in patients w/ severe hepatic disease, history of seizures
• Doses are for children ≥4 yr old
Intestinal fl ukes (F buski, H heterophyes, M yokogawai):25 mg/kg PO 8 hrly x 1-2 days or 40 mg/kg PO single doseO viverrini:25 mg/kg PO 8 hrly x 2-3 daysor40 mg/kg PO single dose P westermani:25 mg/kg PO 8 hrly x 2-3 days or40 mg/kg PO single doseS haematobium:20 mg/kg/dose PO 12 hrly x 1 day or40 mg/kg PO single dose for 1 dayS japonicum, S mekongi:20 mg/kg PO 4-6 hrly x 3 doses for 1 dayor40-60 mg/kg PO single dose for 1 dayS mansoni:20 mg/kg/dose PO 12 hrly x 1 day or40 mg/kg PO single dose for 1 dayTapeworms:5-25 mg/kg PO single dose© M
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Gastroenteritis - Parasitic (12 of 13)
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
Dosage Guidelines
ANTHELMINTICS (CONT’D)
Drug Dosage Remarks
Pyrantel (Pyrantel pamoate)
Ascariasis:10 mg/kg PO single doseMax dose: 1 g/day
Adverse Reactions• GI eff ects (N/V, anorexia, abdominal cramps,
diarrhea); CNS eff ects (headache, dizziness, drowsiness, insomnia); Other eff ects (elevated liver enzymes, skin rashes)
Special Instructions• Use w/ caution in patients w/ hepatic
impairment, anemia, malnutrition
Enterobiasis:10 mg/kg PO single doseMay be repeated after 2 wkMax dose: 1 g/dayHookworms:10 mg/kg PO once daily x 3 days
Tiabendazole (� iabendazole)
Strongyloidiasis:25 mg/kg PO 12 hrly x 2-3 daysor50 mg/kg/day PO as a single doseMay be given >5 days for dissemi-nated diseaseMax dose: 3 g/day
Adverse Reactions• GI eff ects (anorexia, N/V, diarrhea, abdominal
pain); CNS eff ects (headache, dizziness, fatigue, drowsiness); Ocular eff ect (disturbance of color vision); Otic eff ect (tinnitus); Dermatologic eff ects (pruritus, rashes); Hematologic eff ect (leukopenia); Other eff ects (liver cholestasis or parenchymal damage, hyperglycemia)
Special Instructions• Use w/ caution in patients w/ hepatic or renal
impairment, malnutrition, anemia or dehydration
Triclabendazole F hepatica:≥6 yr: 10 mg/kg PO 12 hrly x 2 doses
Adverse Reactions• GI eff ects (abdominal pain, N/V, diarrhea,
decrease/loss of appetite); CNS eff ects (dizziness, headache); Dermatologic eff ects (jaundice, itching); Other eff ects (sweating, weakness, chest pain, fever, dorsal pain, cough)
Special Instructions• Use w/ caution in patients w/ cardiac
pathologies (arrhythmia, syncope), congenital galactosemia, glucose malabsorption, galactose/lactose defi ciency
OTHER ANTIPROTOZOAL AGENTS
Drug Dosage Remarks
Furazolidone Giardiasis:1.25 mg/kg/dose PO 6 hrly x 2-5 daysMay be given up to 10 days
Adverse Reactions• CNS eff ects (dizziness, drowsiness, headache, malaise); Other
eff ects (N/V, allergic skin reactions, darkening of the urine)Special Instructions• Use w/ caution in patients w/ G6PD defi ciency when
administering large doses for prolonged periods• Contraindicated in patients <1 mth due to possibility of
producing hemolytic anemia© MIM
S
© MIMS PEDIATRICS 2020
GAST
ROEN
TERI
TIS
- PAR
ASIT
IC
B13
Gastroenteritis - Parasitic (13 of 13)
Dosage Guidelines
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.Please see the end of this section for the reference list.
ADJUNCTIVE AGENTS
SUPPLEMENTS & ADJUVANT THERAPY
Drug Dosage Remarks
Bovine colostrum ≥12 mth: 1 sachet/day (7 g) PO x 3 days
Special Instructions• Mix the contents of 1 packet w/ 30 mL water in a cup• Use w/ caution in patients w/ allergy to milk &/or egg
Lactobacillus spp (L casei, L acidophilus,L rhamnosus, L bulgaricus)/ Bifi dobacterium spp (B breve, B infantis)/Streptococcus thermophilus
1 sachet (1 g) PO 24 hrly x 4-7 days
Special Instructions• Contents of the sachet may be added to food/water/
milk/juice• Use w/ caution in patients w/ allergy to fi sh, soya or
milk
ELECTROLYTES
Drug Dosage Remarks
Sodium chloride, Trisodium citrate, Potassium chloride, Glucose (NaCl, KCl, Trisodium citrate, Glucose anhydrous)
<2 yr: 1 sachet (5.125 g) PO for the 1st 2 hr, then up to 8 hrly2-5 yr: 1 sachet (5.125 g) PO 3x for the 1st 2 hr, then up to 4 hrly>5 yr: 1 sachet (5.125 g) PO 4x for the 1st 2 hr, then up to 2 hrly
Adverse Reactions• Hypernatremia, Na & water retention, N/VSpecial Instructions• Dissolve 1 sachet in 250 mL water• Use w/ caution in patients w/ renal impairment,
severe dehydration, severe & prolonged diarrhea, glucose malabsorption, vomiting, inability to drink
ANTIDIARRHEALS
Drug Dosage Remarks
Bacillus clausii 1-2 vials of 2 billion/5 mL susp
Adverse Reactions• Dioctahedral smectite may aggravate constipation• Lactobacillus may cause intestinal fl atus• Lyophilized Saccharomyces may cause
constipation, fl atulence, thirst• Racecadotril may rarely cause drowsiness, N/V,
constipation, headacheSpecial Instructions• May be diluted to or taken w/ water, milk, tea, food• Lyophilized Saccharomyces should be used w/
caution in patients allergic to yeast, immunocompromised, or previously or currently on antibiotic therapy
• Racecadotril & Dioctahedral smectite should not be used in patients w/ renal or hepatic impairment, fructose intolerance, glucose & galactose malabsorption syndrome, sucrase-isomaltase defi ciency, acute dysentery w/ bloody stool & high fever, diarrhea associated w/ broad-spectrum antibiotic
Dioctahedral smectite <1 yr: 3 g/day PO in 2-3 divided doses1-2 yr: 3-6 g/day PO in 2-3 divided doses>2 yr: 6-9 g/day PO in 2-3 divided doses
Lactobacillus spp (L reuteri, L acidophilus, L rhamnosus, L sporogenes)
450 mg PO 24 hrly
Lyophilized Saccharomyces boulardii
250 mg PO 24 hrly
Racecadotril Day 1: 1.5 mg/kg/dose PO w/ 1 initial dose then 2 divided doses dailySubsequent days:3 divided doses dailyMax duration: 7 days
© MIM
S
© MIMS PEDIATRICS 2020