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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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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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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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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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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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

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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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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


constipation); CNS eff ects (weakness, dizziness, headache, mood changes); Other eff ects (anorexia, darkening of urine)



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


constipation); CNS eff ects (weakness, dizziness, headache, mood changes); Other eff ects (Candidal infection, anorexia, darkening of urine)




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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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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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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Dosage Guidelines


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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Dosage Guidelines


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)


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

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Dosage Guidelines



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

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