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The drugs
listed in this section are among the most important for preventing or
treating many travel-related illnesses (e.g., malaria, travelers'
diarrhea, and acute mountain sickness).
ACETAZOLAMIDE (Diamox®)
125 mg or 250 mg tablet, or 500 mg
timed-release sequel for acute
mountain sickness (AMS)—prevention and treatment
- Dose (Prevention
of AMS): 125 to 250 mg twice daily and continued for 2 days
while at maximum altitude.
- Dose (Treatment of AMS): 250 mg
twice daily until symptoms resolve.
- Acetazolamide is the
drug of first choice for preventing AMS. About 60% effective.
- Acetazolamide is a carbonic
anhydrase inhibitor and stimulates
respiration by causing metabolic acidosis. It has been shown
to accelerate acclimatization.
- Major
Indications: (1) A
forced
rapid ascent (1 day) to altitudes over 3000 meters - for
example, flying in to Lhasa, Tibet (2) A rapid gain in
sleeping elevation - for example, ascending 1000 meters (3,300
feet) altitude in one day, and (3) If you have a history of
recurrent AMS.
- It does not coverup symptoms
of AMS: if you feel well on acetazolamide, you are well.
- If you ascend with symptoms of
AMS, acetazolimide will not protect you.
- Indicated for
altitudes above 8000 feet, especially if there is rapid ascent
(as above).
- If you don't take
acetazolamide to prevent AMS, consider carrying it for stand-by treatment.
- Side
effects: The most common side effect is a tingling "pins and needles"
sensation of the face, lips, or around the mouth.
- Diamox is a
mild diuretic. Give with caution to climbers who are allergic to sulfa.
- Hypothermia, dehydration and
low blood sugar (due to not eating) share many symptoms and
aggravate the symptoms of AMS.
- Note:
The treatment for more severe AMS is descent.
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ALBENDAZOLE (Albenza,
Eskazole, or Zentel)
Albendazole is a member of the benzimidazole compounds used as a
drug indicated for the treatment of a variety of parasitic infestations.
Albendazole is approved to treat:
In Africa,
albendazole is being used to treat lymphatic filariasis as part of
efforts to stop transmission of the disease. In sub-Saharan Africa,
it is used in conjunction with ivermectin, and elsewhere in the
world, albendazole is used in combination with diethylcarbamazine.
Dosage
for echinococcosis
-
Albendazole 400 mg twice daily with meals for 28 days.
-
For
patients weighing <60 kg, use a total of 15 mg/kg/day in divided
doses with meals. Maximum total daily dose is 800 mg.
-
Treatment interval: 28-day cycle followed by a 14-day
albendazole-free interval for a total of 2-3 cycles. For human
alveolar echinococcosis, continuous treatment may be a promising
alternative.
Dosage for
neurocysticercosis
-
Albendazole 400 mg twice daily with meals for 8 to 30 days
-
For
patients weighing <60 kg, use a total of 15 mg/kg/day in divided
doses with meals for 8 to 30 days. Maximum total daily dose is
800 mg.
Note:
Patients being treated for neurocysticercosis should receive
appropriate steroid and anticonvulsant therapy as required. Oral or
intravenous corticosteroids should be considered to prevent cerebral
hypertensive episodes during the first week of treatment.
Off-label
uses include treatment for:
-
Capillariasis - 400 mg/day given in divided doses for 20 days
for new cases and for 30 days for relapses of cases.
-
Cutaneous larva migrans - 400 mg daily for 3 days or 200 mg
twice daily for 5 days with meals.
-
Common
roundworms (ascariasis) - 400 mg given as a single oral dose.
Contraindicated during pregnancy and in children under 2 years.
-
Hookworms (ancylostomiasis and necatoriasis) - 400 mg one-time
oral dose.
-
Pinworms (enterobiasis or oxyuriasis) - 400 mg orally once;
repeat in 2 weeks.
-
Tapeworms
- <60 kg: 3 cycles of 15 mg/kg/d orally divided bid for 28 days
with 14-day drug-free intervals in between.
Hydatid cyst infestation: <60 kg: 15 mg/kg/day divided bid for
8-30 days; >60 kg: 400 mg bid for 3 cycles as above; not to
exceed 800 mg/day.
Symptomatic neurocysticercosis infections: >60 kg: 400 mg orally
bid for 8-30 days; not to exceed 800 mg/day.
-
Whipworms (trichuriasis)
- Oral treatment with mebendazole for 3 days is commonly used in
symptomatic infections. Albendazole can be used as an
alternative therapy.
Albendazole is a second-line drug for treatment of acute and chronic strongyloidiasis.
(Note; Ivermecton is the drug of choice for strongyloidiasis.)
Side
effects: This medication may cause dizziness, headache, fever,
nausea, vomiting, or temporary hair loss. In rare cases it may cause
persistent sore throat, severe headache, seizures, vision problems,
yellowing eyes or skin, dark urine, stomach pain, easy bruising,
mental/mood changes, very stiff neck, change in amount of urine.
Allergic reactions are also possible.
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Riamet
fixed-dose antimalarial
tablets contain two active ingredients, artemether (20 mg) and lumefantrine
(120 mg).
Artemether is a lipid-soluble derivative of artemisinin, an herb derived from
the leaves of Artemisia annua, and widely used in China and
Southeast Asia for treatment of malaria. Because artemisinin itself
has physical properties such as poor
bioavailability that limit its effectiveness, semi-synthetic
derivatives of artemisinin, including
artemether and
artesunate, have been developed.
-
Artemether is a lipid-soluble
derivative of artemisinin suitable for oral, rectal or
intramuscular use.
-
Lumafantrine is an antimalarial
drug chemically related to halofantrine and quinine.
-
Riamet®
is one of the fastest-acting fixed-combination anti-malarials
with >95% cure rates - even in multi-drug resistant areas.
-
Adult treatment dose: 4 tablets twice daily for 3 days.
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Water-soluble derivative of
artemisinin. More effective than quinine or quinidine for treating
severe falciparum malaria. Available only from the CDC (there is no
charge). The drug will be released by the CDC Drug Service from one
of the 20 CDC quarantine stations located throughout the country.
After the acute phase of illness, artesunate
must be partnered with a longer-acting antimalarial to ensure a high
probability of cure. These drugs include doxycycline (or clindamycin in
pregnant women), or full courses of treatment with atovaquone/proguanil or
mefloquine.These drugs can be initiated when the patient can tolerate oral
medication.
You must contact the CDC to obtain artesunate.
Call the CDC Malaria Hotline:
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Atovaquone 250 mg and Proguanil 100 mg; Pediatric formulation: Atovaquone 62.5 mg and Proguanil 25 mg.
Used for
the prevention or treatment of acute, uncomplicated falciparum malaria and other
malarias.
-
Atovaquone/proguanil (Malarone) is considered the drug of choice for
travelers taking relatively brief trips to chloroquine-resistant areas
because of its favorable safety profile and its short period of pre-exposure
and postexposure dosing. The dosing schedule is ideal for frequent
travelers, travelers who depart on short notice, and for those who live in
the tropics and have repeated short exposures outside urban areas.
- Prevention dose (adult): 1 tablet daily, starting 1-2 days prior to entering a malarious
area and continuing for 7 days after leaving the area of exposure.
- Prevention dose (pediatric):
pediatric
dose is based on body weight: 11-20 kg: 1 pediatric tablet daily; 21-30
kg: 2 pediatric tablets; 31-40 kg: 3 pediatric tablets; more than 40 kg, use
4 pediatric tablets or 1 adult tablet.
- Off-label use for children
5-11 kg: 1/2
pediatric tablet daily (recommended by CDC).
- Treatment dose (adults): 400mg (4 tabs),
single dose, daily x 3 days.
- Not FDA-approved for use in
pregnancy and not recommended for use in pregnancy by the CDC, but the individual components of this
drug have been shown to be safe in pregnancy; therefore, the use of atovaquone/proguanil in pregnancy should be considered when the
probable benefits outweigh possible risks.
- Side
effects: Relatively few. Side effects include headache, upset stomach,
cough, and a rash. Atovaquone/proguanil should be taken at the
same time each day with food or a milky drink. If vomiting occurs within one
hour of taking a dose, repeat the dose.
- May not be
effective if used with tetracycline or rifampin (because of decreased
absorption).
For malaria
treatment: Atovaquone/proguanil (Malarone) is considered, in most cases, to
be the drug of choice for self-treatment of malaria when it is not being taken
for prophylaxis. The treatment dose is 4 tablets, once daily, for 3 days.
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250 mg and 500 mg tablets
and oral suspension
for travelers'
diarrhea and other infections
- Available in
tablet, capsule, and oral suspension.
- Safe in
pregnancy.
- Adult dose for travelers' diarrhea and most other infections: 500 mg (2
tablets) the first day, followed by a single 250 mg tablet daily for the
next 4 days OR 2 tablets (500 mg) daily for
3 days.
-
Alternative adult dosing for travelers'
diarrhea: Single 1-g oral dose. Single-dose azithromycin is as effective
as single-dose levofloxacin.
- Pediatric
dose: 10-12 mg/kg as a single dose the first day, followed by 5-6 mg/kg
on days 2-5.
- Azithromycin is indicated to treat a variety of infections, such as
strep pharyngitis, bronchitis, community acquired pneumonia, otitis media, sinusitis, and some skin infections (e.g., cat
scratch cellulitis). It is not effective for methicillin resistant
staph aureus (MRSA).
- Effective for
gonococcal urethritis (gonorrhea) and nongonoccal urethritis
and cervicitis. Dosage: 1 g orally as a single dose for chlamydia. A
2-g dose is effective as monotherapy for gonorrhea (GC) but is poorly tolerated,
due to gastrointestinal side effects.
- Combining single-dose azithromycin, 1 g
orally, with cefixime, 400 mg orally,
will effectively treat urethritis due to GC with chlamydia co-infection.
- Azithromycin is effective against typhoid fever in a dose of 1000 mg (4
tablets) the first day, followed by 500 mg (2 tablets) daily for an
additional 6 days. For children, the treatment for typhoid is 10 mg/kg daily
for 7 days.
- A
single 1-g
dose is effective treatment for cholera.
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This is a cephalosporin antibiotic that is effective
against most bacteria causing infectious diarrhea but there have been
reports of Shigella resistance. Cefixime is also a useful drug for
treating ear infections (otitis media), pharyngitis and tonsillitis,
acute bacterial bronchitis, urinary tract infections, and gonorrhea.
Cefixime
is available in 400-mg tablet and liquid form. Duration of therapy
depends upon the clinical diagnosis. Travelers' diarrhea and urinary
tract infections may respond to 3 days of therapy; ear infections,
bronchitis, and pneumonia may need 5-10 days treatment; strep
pharyngitis requires a full 10-day course of treatment.
Gonorrhea Cefixime is
now recommended as single-dose treatment for uncomplicated gonorrhea (urethritis,
pharyngitis, cervicitis, proctitis). The 400-mg tablets are once again
available in the U.S. (June 2008)
Note: When
treating gonorrhea, give a single1-g dose of azithromycin, or a 7-ay
course of doxycycline, to treat possible co-infection with chlamydia
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Intravenous or intramuscular. Vials of 250 mg, 500 mg, 2 gm, 10
gm.
Treatment of gonorrhea Because of the emergence of
quinolone-resistant neisseria bacteria, the cephalosporins, primarily
ceftriaxone and cefixime, have become the treatment of choice for
uncomplicated gonococcal urethritis and pelvic
inflammatory disease (PID).
Dosage
Single intramuscular injection of
125/250 mg
Other indications:
-
Lyme disease
-
Typhoid fever
- Meningococcal meningitis
- Meningococcal meningitis prophylaxis
- Bacterial dysentery (shigellosis)
- Leptospirosis
- Bacterial septicemia
- Bone, joint, skin and skin structure infections
- Intra-abdominal infections (with
metronidazole)
- Upper respiratory tract infections (otitis
media)
- Lower respiratory tract infections (CAP)
- Complicated and
uncomplicated urinary tract infections
- Brain abscess (with metronidazole)
-
Appendicitis (with
metronidazole)
-
Peritonitis, spontaneous bacterial &
secondary
-
Endocarditis
-
Diabetic foot infections (with metronidazole or
clindamycin)
- Meningococcal meningitis prophylaxis: 125 mg x1 (<15 yrs);
250 mg x1 (>15 yrs). Due to reports of fluoroquinolone
resistance,
rifampin, ceftriaxone, and
azithromycin is recommended in selected counties in North
Dakota and Minnesota.
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500 mg (300 mg base) & 250 mg (150 mg base). (Trade
names in other countries include Avloclot, Nivaquine, and Resorchin.) for malaria
prevention (prophylaxis) and treatment of chloroquine-sensitive
P. vivax,
chloroquine-sensitive P.
falciparum, P. ovale, P. malariae.
- For
sensitive P. vivax and P. falciparum, chloroquine remains the
drug of choice to prevent malaria. However, because of widespread
chloroquine-resistant P. falciparum, the use of chloroquine is
limited to persons traveling in Central America, the Caribbean, and parts of
the Middle East.
- While
chloroquine remains effective against most strains of P. ovale and
P. malariae, resistance to P. vivax is increasing, particularly
in the South Pacific, Southeast Asia, and parts of South America (Guyana).
- Prevention dose (adults): 500 mg salt (300 mg base) once weekly, beginning one week before
and continuing 4 weeks after leaving the malarious area. Starting
chloroquine before you leave gives you a protective blood level and also
lets you know if any unusual side effects will occur.
- Child dose: 8.3 mg/kg salt (5 mg/kg base) once weekly, up to maximum adult
dose of 500 mg salt/week.
- Treatment dose (adults): chloroquine phosphate 1 gm salt (600mg base)
once, then 500 mg mg salt (300mg base) 6 hr later, then 500 mg at 24 hr and
48 hr.
- Generic
chloroquine tablets are sold in the United States in strengths of 250 mg and
500 mg. Only the tablet form of chloroquine is available in the United
States. For young children, liquid chloroquine is generally available
overseas.
- Side effects: Chloroquine is generally well tolerated; nausea, however, is
not uncommon. Taking chloroquine with meals can usually control
gastrointestinal side effects. Dizziness, headache, blurred vision, and
itching may also occur, but these symptoms will rarely require you to stop
taking the drug.
- Chloroquine
can safely be taken by pregnant women and children, including infants.
- Caution:
An overdose of chloroquine (even one tablet in a small child) can be fatal.
The drug should be kept in a child-safe container at all times.
- Chloroquine
is considered safe when taken regularly for malaria prevention, even for
long periods of time (years).
- Should not be used by travelers with
psoriasis, a history of psychosis, or those with prolonged QT interval on
their electrocardiogram.
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500 mg and 250 mg tablets
for travelers'
diarrhea and other infections
- Used
primarily to self-treat (and occasionally prevent) travelers' diarrhea
caused by bacteria.
- Usual dose: 500 mg twice daily for 1-3 days.
- Single-dose treatment: 750 mg of Cipro,
in a single dose, can be taken as immediate treatment for travelers'
diarrhea. If taken early, this may be enough to stop symptoms in a few
hours. If diarrhea persists after 12 hours,
continue Cipro, 500 mg twice daily, for 2-3 more days.
- For greater
effectiveness, take Cipro with the antidiarrheal agent Imodium (loperamide).
Take 2 caplets of Imodium (loperamide) with the first dose of Cipro. Follow
Imodium-AD package directions regarding further doses.
- Do not use
Imodium-AD (loperamide) if the diarrhea is accompanied by bloody stools, a
high fever, or severe abdominal pain.
- Cautions:
The use of Cipro (ciprofloxacin) in pregnant women, and children under age
18, is controversial; however, for more severe diarrhea (especially when
there is fever and blood in stools), treatment for these groups is accepted
by most infectious disease specialists.
- Do not take
Cipro with milk, yogurt, antacids, probenecid, theophylline, or Carafate
(sucralfate) because absorption will be reduced.
- Side
effects: Cipro may cause nausea, diarrhea, headaches, dizziness, or
lightheadedness. Cipro may cause (rarely) photosensitivity reactions if
patients are exposed to strong sunlight.
- Other infections:
Ciprofloxacin may also be used for respiratory tract infections; some sinus
infections; typhoid fever; infections of the bladder, kidney, and prostate,
and anthrax.
- Fluoroquinolones are no longer recommended
for the treatment of gonorrhea due to a high prevalence of fluoroquinolone
resistance in N. gonorrhoeae.
- Ciprofloxacin is used against cholera in a single 1-g
dose in adults, but single-dose azithromycin (1 g
orally) is probably more effective.
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4 mg tablets and intramuscular (IM)
injectable preparation: For treating more acute mountain
sickness (AMS) and high-altitude cerebral edema (HACE). May also be
used to prevent AMS.
- Life-saving drug in cases of
high-altitude cerebral edema (HACE).
- Used for treating moderate- to
severe -altitude illness (AMS) and HACE.
- Treatment dose for high altitude
cerebral edema (HACE): 8 mg IM STAT then 4 mg im/orally every 6 hours.
- For prevention of AMS: 4 mg orally
twice daily starting 18 to 24 hours prior to ascent. Indicated
especially for people ascending very rapidly (e.g., on a
high-altitude rescue mission) or unable to take acetazolamide
because of allergy or intolerance.
- Especially useful to
facilitate descent or when there is a delay in descending.
- Combine dexamethasone with
oxygen or a
Gamow® Bag
(a portable fabric hyperbaric chamber) for better results when
treating HACE.
- When treating less severe
AMS: Administer dexamethasone 4 mg im/orally every 6 hours x 2-4 doses.
No further ascent until the climber is well and at least
18 hours after last dose.
- Dexamethasone can be combined
with acetazolamide for better effect when treating AMS.
- Dexamethasone decreases
systolic pulmonary artery pressure and may reduce the incidence
of HAPE in climbers with a history of HAPE.
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100 mg tablets. Used to
prevent chloroquine-resistant falciparum malaria; to treat other
infections such as Lyme disease and rickettsial infections. Treatment
indications include:
- Adjunctive
treatment, with quinine and other antimalarials, for falciparum malaria.
- For malaria prophylaxis:
Take 100 mg daily and continue for
4 weeks after leaving malarious area. Pediatric dose (above 8 years
of age): 2 mg/kg/day, up to the adult dose of 100
mg/day.
- Effective in
many other infections, such as Lyme disease, brucellosis, Mediterranean
spotted fever and other rickettsial infections, (e.g., typhus, Rocky
Mountain spotted fever), anthrax, relapsing fever, anaplasmosis and ehrlichiosis,
Q fever, plague, psittacosis, tularemia, trachoma, yaws, and syphilis
(alternative treatment).
- Doxycycline can be used to treat
respiratory infections, such as sinusitis, bronchitis, and bacterial and
atypical pneumonia.
- Effective against methicillin-resistant
Staph aureus (MRSA).
- Sexually-transmitted diseases, such as nongonococcal urethritis due to chlamydia
and Ureaplasma urealyticum; lymphogranuloma venereum, and granuloma
inguinale.
- A single 200 mg dose, administered within
72 hours of a tick bite, is effective prophylaxis against Lyme disease.
- Do not take
with milk or antacids.
- Swallow with
adequate amounts of fluids and in the upright position to avoid the risk of
the tablet sticking and causing esophageal ulceration.
Side effects: doxycycline can cause a photosensitivity reaction characterized
by sunburn-type symptoms. Use a broad-spectrum (UVA + UVB) sunblock to
reduce UV effects. May predispose women to vaginal yeast infections; women
may wish to carry an antifungal drug (such as Diflucan) for self-treatment.
Studies in pregnant women have
demonstrated a risk to the fetus. However, the benefits of therapy
in a life threatening situation or a serious disease, may outweigh
the potential risk.
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This drug is active against most bacterial
causes of travelers’ diarrhea, as well as Giardia (about 80%
effective), making furazolidone
useful as a broad-spectrum treatment when the cause of the diarrhea is
not known. Furazolidone is also available in a liquid preparation.
Adult dosage:
100 mg (1 tablet) 4 times daily for 3 days; for giardiasis, treatment is for 7 to 10 days
Child dosage: 5 years and older—25 to 50 mg (1/4
to 1/2 tablet) 4 times daily
Liquid furazolidone contains 50 mg per tablespoon (15 mL)
5
years and older—1/2 to 1 tablespoon (7.5 mL to 15
mL) 4 times daily
1
to 4 years—1 teaspoon to 11/2 teaspoons (5 mL to
7.5 mL) 4 times daily
1
month to 1 year—1/2 teaspoon to 1 teaspoon (2.5 mL
to 5 mL) 4 times daily
Caution in G-6-PD deficiency whenn
administering for prolonged periods.
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Ivermectin is a broad-spectrum
antiparasitic agent. It is mainly used in humans in the treatment of
onchocerciasis, but is also effective against other worm
infestations (such as strongyloidiasis, ascariasis, trichuriasis and
enterobiasis). More recent evidence supports its off-label use in
the treatment of mites such as scabies, usually limited to cases
that prove resistant to topical treatments and/or who present in
advanced state (such as Norwegian scabies), but more recently found
to be effective against most mites and some lice too. It is sold
under brand names Stromectol in the United States and Mectizan in
Canada by Merck. Mectizan is currently being used to help eliminate
river blindness (onchocerciasis) in the Americas and stop
transmission of lymphatic filariasis around the world.
Onchocerciasis dosage 150
mcg/kg/d orally as single dose every 6-12 months
Ivermectin is the drug
of choice for the treatment of uncomplicated strongyloidiasis.
Ivermectin does not kill the strongyloides larvae only the adult
worms so therefore repeat dosaging may be necessary to properly
eradicate the infection. There is an auto-infective cycle of roughly
two weeks in which Ivermectin should be re-administered however
additional dosaging may still be necessary as it will not kill
strongyloides in the blood or larvae deep within the bowels or
diverticuli. Other drugs that are effective are albendazole and
thiabendazole (25 mg/kg twice daily for 5 days). All patients who
are at risk of disseminated strongyloidiasis should be treated. It
is not clear what the optimal duration of treatment for patients
with disseminated infectious should be.
Strongyloides dosage 200
mcg/kg/d orally for 2 days; may repeat course in 14 days
Caution in pregnancy: breastfeeding
women with infants <3 mo, and in elderly persons with serious
medical problems; immunocompromised patients may require repeated
courses of therapy; adverse effects typically occur within first 48
h after first dose and include edema, pruritus, arthralgias, and
postural hypotension; may be associated with nausea, vomiting, mild
CNS depression, and drowsiness; caution in regions where
onchocerciasis and Loa Loa (another filarial disease) are both
endemic; patients with high microfilarial loads of Loa Loa are
susceptible to encephalopathy upon treatment with ivermectin.
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LEVOFLOXACIN
(Levaquin®)
500 mg, 250 mg tablets.
Levofloxacin is a fluoroquinolone (quinolone) antibiotic used to treat travelers' diarrhea and
other infections
- Levofloxacin
(Levaquin) is an excellent drug to carry for standby self-treatment, not
only for diarrhea, but also for a variety of other infections such as
pneumonia, bacterial bronchitis, urinary tract infections, and some skin infections
(excluding MRSA),
- Use by
children under 18 is accepted by most infectious disease consultants for
severe disease (e.g., diarrhea with fever and bloody stools).
- Category C
pregnancy drug: To be used in pregnant women only when the risk of infection
outweighs possible adverse effects. Indicated especially for cases with severe diarrhea, high
fever with toxicity, especially when there is the threat of dehydration.
- Dose:
500 mg once, or 500 mg twice daily for 1-3 days, if the drug is continued
beyond the first dose.
- Symptoms
will be controlled faster if taken with Imodium (loperamide).
- Take with
meals, or on an empty stomach.
- Do not take
with antacids containing magnesium or aluminum, sucralfate (Carafate), or
iron preparations. These should be taken 2 hours before, or 2 hours after,
taking Levaquin.
Other uses:
Dosage:
Effective
against typhoid fever in a dose of 500 mg daily for 5-7 days.
Note: The fluoroquinolones are no longer recommended for treating
gonorrhea because of resistance to fluoroquinolones.
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2 mg caplets; Imodium®-AD liquid 1 mg/5mL;
Imodium® Advanced 2 mg chewable tablets) for treatment of mild-to-moderate travelers' diarrhea
- Prescription
not required. Available over the counter in caplet, chewable tablet, and
liquid form.
- Loperamide
(Imodium-AD) is an antimotility and antisecretory drug that reduces the
rapid discharge of stool, but does not treat the underlying infection.
- Dose:
Adults and children 12 years of age and older: 2 caplets (4 mg) or chewable
tablets immediately for diarrhea, then one 2 mg caplet or chewable tablet
after each bowel movement. Do not exceed 8 caplets in 24 hours. Do not use
Loperamide for more than 48 hours.
- Use with
ciprofloxacin (Cipro), levofloxacin (Levaquin), or azithromycin (Zithromax)
for greater effectiveness.
- NOTE: When diarrhea is associated with high fever and bloody stools
(dysentery), Loperamide (Imodium-AD) should not be used as the primary
treatment. An antibiotic is the treatment of choice for severe diarrhea
and dysentery. However, it is safe to take 1 or 2 doses of loperamide when
an antibiotic is taken at the same time. (Loperamide alone is usually
avoided when a high fever or bloody stools are present because it is
possible, theoretically, for symptoms to be prolonged if intestinal motion
is reduced in the face of an invasive bacterial gut wall infection. However,
this has never been conclusively demonstrated.)
- Pediatric dose: Children 9-11 years old (27-43 kg): 2 teaspoons or 1 caplet or
chewable tablet after the first loose bowel movement, and 1 teaspoon or 1/2
caplet or chewable tablet after each subsequent loose bowel movement, but no
more than 6 teaspoons, caplets, or chewable tablets a day for no more than 2
days.
- Children
6-8 years old (22-26 kg): 2 teaspoons or 1 caplet or chewable tablet
after the first loose bowel movement, and 1 teaspoon or 1/2 caplet or
chewable tablet after each subsequent bowel movement, not to exceed 4
teaspoons or 2 caplets or chewable tablets a day for more than 2 days.
- Children 2-5 years old (11-21
kg): 1 teaspoon after the first loose bowel
movement followed by 1 teaspoon after each subsequent loose bowel movement.
Do not exceed 3 teaspoons a day.
- Do not use
loperamide under 2 years of age.
- The
cornerstone of treatment of travelers' diarrhea in children is oral fluid
replacement.
- Antibiotics
should be given to a child with moderate-to-severe diarrhea.
- Although
azithromycin (Zithromax) is the preferred antibiotic to treat
travelers'diarrhea in children, a fluoroquinolone antibiotic (Cipro or
Levaquin) should be considered for severe diarrhea and dysentery (bloody
diarrhea, usually with fever). No significant adverse effects have been seen
in children who have taken fluoroquinolones, despite the theoretical
concerns about joint cartilage injury.
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250 mg, 375 mg, 500 mg, 750 mg (extended release) tablets;
intravenous solution; topical cream & gel. First line agent for
treating giardiasis, amebiasis, and trichomoniasis. Metronidazole is
the gold standard against anaerobic infections. (Additional
antibiotic coverage needed for combined aerobes/anaerobes
infections.)
- Intra-abdominal infections; skin and skin structure
infections; bone and joint infections.
- Bacterial septicemia; endocarditis (caused by Bacteroides
spp.).
- Gynecologic infections (endometritis, endomyometritis, tubo-ovarian
abscess).
- Lower respiratory tract infections (in combination with
another agent with activity against microaerophilic
Streptococcus).
- Adjunct treatment for gastritis and duodenal ulcer
associated with Helicobacter pylori.
- CNS infections (meningitis and brain abscess).
- Treatment of amebiasis, giardiasis, dracunculiasis, and
trichomoniasis.
- Periodontal disease.
- Bacterial vaginosis.
- C. difficile colitis
Adult dosages:
- Giardiasis: 250 mg orally
three times daily x 5-7 days.
- Amebiasis: 750 mg orally three
times daily x 5-10 days.
- C. difficile colitis: 500 mg orally
three times daily or 250 mg
orally four times daily x 10-14 days.
- Bacterial vaginosis: 500 mg twice daily x 7days or
Flagyl
ER 750 mg orally once daily x 7 days.
- Trichomoniasis: single 2 g x 1 dose or 500 mg orally
twice daily x
7 days (alternative).
- Susceptible anaerobic infections: 250-500 mg orally
three times daily or
500 mg IV every 6 hours or consider 0.5-1 gm orally or IV
twice daily.
Oral vancomycin and metronidazole are equivalent in the treatment
of C. difficile- associated colitis with comparable rates of
response and relapse, but most experts recommend oral vancomycin in
severe disease.
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250 mg (Trade names in other countries include Eloquin®
and Mephaquin®) for malaria
prevention and treatment
- Effective
for prevention of chloroquine-sensitive and chloroquine-resistant malaria
and other malarias.
- Not
recommended for malaria self-treatment because of potentially severe
neuropsychiatric side effects.
Adult
dose (prophylaxis): 1 tablet (250 mg) weekly, beginning 1-2 weeks before
departure, continuing during exposure, and for an additional 4 weeks after
leaving the malarious area. Do not take on an empty stomach.
Adult
dose (treatment): 750 mg by mouth as initial dose, followed
by 500 mg given 6-12 hours after initial dose. Total dose: 1,250 mg
Pediatric dose: 5 mg/kg for infants under 15 kg; 1/4 tablet for those weighing
15-19 kg; 1/2 tablet for those weighing 20-30 kg; and 3/4 tablet for those
weighing 31-45 kg.
- Contradicted
for travelers with a history of seizures, cardiac conduction abnormalities,
depression and/or psychosis.
- May be used
by travelers taking beta blockers if they have no underlying cardiac
arrhythmias.
- Should not
be used with quinine, quinidine, halofantrine, chloroquine, or
anticonvulsants.
- Mefloquine (Lariam)
may cause first-degree AV block and prolong the QT interval.
- Side effects: Generally well-tolerated in prophylactic doses, but about 25%
of users report mild-to-moderate side effects—strange dreams, insomnia, mood
alteration, nausea, dizziness, and weakness. About 5% of travelers taking mefloquine (Lariam) for prophylaxis discontinue the drug, primarily because
of central nervous system side effects. Mefloquine (Lariam) should be
discontinued if irritability, depression, confusion, or paranoia develops.
- Caution:
People involved in tasks that require fine coordination (e.g., airline
pilots, surgeons) should not take this drug.
- Mefloquine (Lariam)
is approved for infants less than 15 kg when travel to a chloroquine-resistant
area is unavoidable.
- Lariam is
approved for use by pregnant women.
- Considered
safe when taken regularly for prevention for as long as necessary.
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10mg and 20mg capsules. Also available in extended release forms
(Procardia XL, Adalat CC) in 30, 60, and 90mg capsules.
- First-line for prevention/treatnent of High Altitude
Pulmonary Edema (HAPE).
- Calcium channel blocker. Reduces pulmonary artery pressure.
- Prevention dose: 20 mg orally three times daily or 30 mg-60
mg of sustained release for prevention of HAPE when started on
the day of ascent and continued for 72 hrs at higher altitudes.
Especially indicated when ascending to altitudes >12,000 feet.
- Treatment dose: 10 mg orally once then 20 mg sustained
release four times daily.
- Side effects: Hypotension and reflex tachycardia, dizziness,
nausea may occur, but cardiovascular effects are usually not a
problem in treating or preventing HAPE.
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Nitazoxanide is a broad-spectrum antimicrobial agent with in vitro
activity against a variety of protozoa, trematodes, cestodes,
nematodes, and anaerobic bacteria.
Nitazoxanide is
approved for the treatment of infectious
diarrhea caused by Giardia
lamblia and Cryptosporidium parvum in patients 1 year of age and older.
Used as treatment for giardiasis, amebiasis, cryptosporidiosis, and
cyclosporiasis.
Nitazoxanide is now available as a liquid preparation (100mg/5mL)
for children 1 to 11 years of age. There is a 500 mg tablet for
older children and adults.
Spectrum of activity:
Cryptosporidia, Entamoeba
histolytica, Giardia lamblia, Cyclospora cayetanensis.
For treating giardiasis, nitazoxanide is at least as effective as
metronidazole.
Dosages:
- Adult: 500 mg orally twice daily x 3 days.
- Child 4-11years: 200 mg orally twice daily x 3 days.
- Child 1-3years: 100 mg orally twice daily x 3 days.
Most experts would treat for 4-6 weeks in immunocompromised patients.
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Each
capsule contains Paromomycin sulfate equivalent to 250mg Paromomycin.
This is an oral aminoglycoside that is non-absorbed from the
intestinal tract and considered to be safe during pregnancy for the
treatment of intraluminal, acute and chronic, noninvasive amebiasis.
As an alternative to metronidazole, it is 60% to 70% effective.
Paromomycin can also be used for the treatment of giardiasis.
Dosage:
Adults and pediatric patients: Usual dose: 25 to 35 mg/kg body
weight daily, administered in three doses with meals, for five to
ten days.
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Praziquantel (Biltricide) is an antihelminthic effective against
flatworms (trematodes). As of 2005, praziquantel is the primary treatment for
human schistosomiasis for which it is usually effective in a single dose. It is also used to treat paragonimiasis, echinococcosis,
cysticercosis, intestinal tapeworms and diseases caused by liver flukes, except for fascioliasis.
Praziquantel is not effective against pinworms or other roundworms.
-
For Schistosoma mansoni and S. hematobium, praziquantel is curative in a
single dose of 40 mg/kg.
-
For the treatment of S. japonicum and S. mekongi, praziquantel,
60 mg/kg, is given in three divided doses 6 hours apart.
-
Retreatment may be indicated 6–12 weeks later to cure prepatent
infections, particularly if eosinophilia, high antibody titers,
or symptoms persist.
-
Clonorchiasis (liver fluke disease) is treated with 75 mg/kg in three divided doses in
1 day.
-
Fasciolopsiasis (giant liver fluke):
a single dose of 15 mg/kg of
praziquantel at bed time is indicated for the treatment of
fasciolopsiasis.
-
Diphyllobothriasis (fish tapeworm disease) and beef tapeworm disease:
single dose of praziquantel, 10 mg/kg.
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Available in 15 mg tablets.
Primaquine
is
is an alternative drug for malaria prophylaxis and for the radical cure of relapsing vivax and P. ovale
malaria. When attempting a radical cure, primaquine
requires the presence of
quinine or
chloroquine in order to work effectively.
If primaquine is given alone, the cure rate is only 21%. This is why
primaquine should always be given with quinine or chloroquine
for terminal prophylaxis.
- Eradicates
dormant liver forms of
P. vivax and P. ovale.
- Effective against gametocytes
of P. falciparum.
-
Field trials in Indonesia, East Africa, and Colombia have shown it
to be an effective (albeit off-label) prophylactic agent. When taken
by adults in a daily dose of 30 mg (or 0.5 mg/kg per day for
children) an effectiveness of 85% to 95% against P. falciparum (as
well as P. vivax and P. ovale) has been demonstrated.
-
Because primaquine is a potent oxidizing agent, capable of
causing breakdown of red blood cells (hemolytic anemia), a
G-6-PD enzyme screening test is required before taking this
drug. Primaquine can also cause
methemoglobinemia.
- People lacking
this enzyme are almost exclusively male, due to the X-linked pattern
of inheritance.
(African American men and
males of Mediterranean descent are most affected.)
Primaquine is contraindicated in
pregnancy because there is no way to test the fetus for the
enzyme deficiency.
- Side effects
include stomach upset, stomach
cramps, nausea, vomiting, and loss of appetite. These may occur
during
the first several days, but are usually
infrequent or mild.
For malaria prophylaxis (off-label use): Start
primaquine 1 day before exposure, take daily
during exposure, and for 3 days after exposure ceases.
-
Adult Dosage: 30 mg (2 tablets) per day for people
>60
kg in weight
-
Child Dosage: 15 mg per day (1 tablet) for people
<60
kg in weight
-
Prevention of malaria relapses (radical cure) caused by
Plasmodium vivax and P.ovale
For radical
cure of vivax malaria: If primaquine is not administered
to patients with proven P. vivax or P. ovale
infection, there is a very high likelihood relapse within weeks or
months (sometimes years). When attempting a so-called radical cure, primaquine
requires the presence of another drug such as
chloroquine,
quinine or artesunate in order to work. If primaquine is given alone, the cure
rate is only 21%. This is why primaquine should always be given with
a
another antimalarial to achieve a cure.
-
Primaquine,
30 mg once daily for 14 days (note that older authorities quote 15 mg instead)
plus another antimalarial.
or,
another option:
- Primaquine, 30 mg twice a day
for 7 days, plus artesunate, 100 mg once a day for 5 days.
Terminal
prophylaxis:
Prophylactic drugs such as chloroquine, mefloquine, and doxycycline work
only in the blood (after the liver phase) to eradicate parasites within
red blood cells. By taking these drugs during exposure and for 4 weeks
after exposure, parasites released from the liver will be killed, and
infections without a dormant liver form (P. falciparum, P. malariae
and P. Knowlesi)
will be completely eliminated. Primaquine and atovaquone/proguanil act
on the liver phase and, therefore, may be discontinued 3 days to 1 week
respectively, after exposure. Only primaquine has the ability to
eradicate dormant forms of relapsing malarias P. vivax and P. ovale.
- Primaquine 30 mg once daily
for 14 days
(note that older authorities quote 15 mg instead) or
45 mg once weekly for 8 weeks. Terminal prophylaxis is
controversial; some travel medicine specialists do not use
terminal prophylaxis but observe the patient and treat only
confirmed P. vivax or P. ovale relapses.
Pneumocystis jiroveci pneumonia
(formerly PCP-pneumocystis carinii pneumonia) Primaquine is also
sometimes used to treat Pneumocystis jiroveci pneumonia.
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10 mg tablets.
Intramuscular/intravenous. For nausea and vomiting associated with
acute mountain sickness (AMS) and other medical conditions.
-
May relieve
nausea and vomiting by blocking postsynaptic dopamine receptors
through anticholinergic effects and depressing the reticular
activating system.
-
Has the
advantage of acting as a respiratory stimulant at high
altitudes.
-
Adult dose:
5-10 mg PO/IM 3 to 4x daily; not to exceed 40 mg/day.
2.5-10 mg IV q3-4h as needed; not to exceed 10 mg/dose or 40
mg/day.
-
Side effects:
Drug-induced Parkinson syndrome (dystonia)
or pseudoparkinsonism occurs quite frequently. This can be
treated with IV Benadryl or Cogentin.
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Quinine is
a first-line therapeutic agent for chloroquine-resistant malaria. It
is not used as a prophylactic drug due to its short half-life and frequent treatment-associated side effects that include nausea,
vomiting, headache, tinnitus, and cardiovascular toxicity. In the
United States, quinine is available as quinine sulfate in 324 mg
capsules under the brand name
Qualaquin. This is the only FDA-approved quinine drug product
available in the U.S.
Qualaquin is approved only for
the treatment of uncomplicated Plasmodium
falciparum malaria. Quinine
for intravenous administration is not available in the United States and quinidine (a
stereoisomer of
quinidine,
or artesunate)
is used when parenteral treatment is required. Note: Quinine
for intravenous administration is available in Canada.
Adult
dosage: 2 tablets (650 mg) every 8 hours for 5 to 7 days.
Quinine capsules are not approved for patients with severe, complicated falciparum malaria.
Quinine treatment should be combined with one of the following:
-
doxycycline, 100 mg twice daily, OR
-
clindamycin, 450-900 mg three times daily
Doxycycline (or tetracycline), or clindamycin should be administered for 5 to 7 days.
The second drug may be administered during or following quinine
therapy.
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Quinidine gluconate (the d-isomer of quinine) is a cardiac drug that
can also be used
to
treat drug-resistant falciparum malaria. Until
artesunate was approved, quinidine had the special status of
being the only intravenously administered antimalarial drug
available in the United States indicated for use in the treatment of
patients with complicated or life-threatening malaria infections.
Dosage: A loading dose of quinidine gluconate, 10 mg/kg
(salt), in saline is given intravenously over 1 to 2 hours, followed
by a constant infusion at 0.02 mg/kg/minute (1.0 to 1.5 mg/kg/hour).
As soon as the parasite density drops below 1% of red cells infected
and the patient is not vomiting, intravenous quinidine should be
stopped and treatment continued with oral quinine sulfate (as
discussed above).
Side Effects: Intravenous quinidine therapy should be
administered in an intensive care unit. Cardiac effects are similar
to those caused by intravenous quinine—dose-related QT interval
prolongation and QRS widening.
Quinidine treatment should be combined with one of the following:
-
doxycycline, 100 mg twice daily, OR
-
clindamycin, 450-900 mg three times daily
Doxycycline or clindamycin should be administered for 5 to 7 days.
The second drug may be administered during or following quinidine
therapy.
Note: Because newer
antiarrhythmic cardiac drugs are replacing quinidine in some
hospitals, physicians should check with their hospital pharmacies to
ensure the availability of this important agent. If there is
difficulty in obtaining the drug locally, physicians should contact
the Eli Lilly Company (24 hours) at 800-821-0538, or the CDC’s
Malaria Branch hotline 770-488-7788; after hours, the on-call person
for malaria can be paged.
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200 mg tablets for treatment of travelers' diarrhea due to
enterotoxigenic E. coli (ETEC).
- Rifaximin is a semisynthetic
rifamycin antibiotic which is not absorbed (<4%) from the GI tract.
- Rifaximin is indicated
for the treatment of patients (≥12 years of age) with travelers’
diarrhea caused by noninvasive strains
of
E. coli. It should
not be used if you have bloody stools and fever (signs of
invasive bacterial enteritis - known as dysentery).
- Usual dosage: 1 tablet (200
mg) three
times daily (without regard to meals) for 3 days.
- Alternate dosage: 2 tablets
twice daily (400 mg twice daily) was found to be as
effective as ciprofloxacin (Cipro; 500 mg twice daily) in
relieving symptoms of travelers' diarrhea due to ETEC.
- Rifaximin is not
effective for travelers’ diarrhea due to Campylobacter jejuni,
which is common in Southeast Asia.
- Rifaximin is safe and
effective for treatment in most patients with travelers'
diarrhea, but it offers no significant advantages over
ciprofloxacin.
Other uses
(off-label):
- Prophylaxis of travelers'
diarrhea - Rifaximin has been shown to be
moderately
effective in preventing diarrhea in college students
traveling to Mexico.
- Rifaximin appears to be
effective when taken prophylactically against diarrhea caused by Shigella bacteria, a
cause of dysentery.
- Small intestine bacterial
overgrowth - Doses as high as 1,600 mg daily x 7 days have been
shown to reduce symptoms.
-
Irritable
bowel syndrome - Patients receiving 400 mg orally
three times daily for 10 days have improved symptoms.
- Hepatic encephalopathy -
patients with hepatic encephalopathy who take rifaximin have
fewer, shorter hospitalizations and less severe disease.
- C. difficile
enterocolitis - rifaximin appears to be a
valid
alternative for the treatment and management of C.
difficile-associated diarrhea,
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SILDENAFIL/TADALAFIL (Viagra®,
Cialis®)
Viagra comes in 25, 50, and 100 mg tablets and is used off-label
for treating pulmonary hypertension causing High Altitude Pulmonary
Edema (HAPE). Cialis (tadalafil) comes in 5, 10, and 20 mg
used for treating
erectile dysfunction but also used off-label
for treating or
preventing HAPE. Viagra and Cialis are in a class of
drugs called phosphodiesterase (PDE-5) inhibitors.
- Phosphodiesterase (PDE-5) inhibitors increase NO (nitric
oxide) levels in the pulmonary vasculature, causing smooth
muscle relaxation and drop in pulmonary artery pressure. This
reduces formation of pulmonary edema fluid.
- Dose: Tadalafil (Cialis) 10 mg orally twice daily for
prevention of HAPE.
- Dose: Sildenafil (Viagra) 50 mg orally three times daily or
tadalafil 10 mg orally twice daily for treatment of HAPE.
- Severe or potentially fatal interaction can occur when PDE-5
inhibitors are taken concurrently with nitrates.
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Available as a metered dose inhaler. Salmeterol (Serevent) is commonly
used as an asthma medication, but it also can hasten the body's
ability to re-absorb pulmonary edema fluid, helping preventmm
high altitude pulmonary
edema (HAPE).
- Dose: 125 mcg (2 puffs)
inhaled twice daily for HAPE prevention and possibly treatment,
starting the day prior to ascent and continued for 2 days at
maximum altitude.
- Mechanism: Upregulates
pulmonary sodium transport across alveolar membranes to increase
clearance of alveolar fluid.
- Side effects: Mild
tachycardia.
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Tadalafil (Cialis) comes in 5, 10, and 20 mg tablets
and
is used
off-label for treating
or preventing
high
altitude pulmonary edema (HAPE).
The drug effectively lowers
pulmonary artery pressure.
Cialis is in a class of drugs called phosphodiesterase (PDE-5)
inhibitors.
- Phosphodiesterase (PDE-5)
inhibitors increase NO (nitric oxide) levels in the pulmonary
vasculature, causing smooth muscle relaxation and drop in
pulmonary artery pressure. This reduces formation of pulmonary
edema fluid.
- Prevention Dose: 10 mg orally
twice daily
- Treatment Dose:10 mg orally
twice daily
- Severe or potentially fatal
interaction can occur when PDE-5 inhibitors are taken
concurrently with nitrates.
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Ttinidazole,
a second-generation nitroimidazole, is an antiprotozoal and
antibacterial agent which is used to treat certain types of parasitic
infections, including the sexually transmitted disease (STD)
trichomoniasis, also known as "trich." Tindamax is also indicated to
treat giardiasis and amebiasis, as well as amebic liver infections.This drug, a
derivative of metronidazole, has similar side effects to
metronidazole, but has a shorter treatment course.
Giardiasis
-
Tindamax is the only single-dose oral
therapy approved to treat giardiasis. The dose in adults is
2 g x 1 dose.
-
For children older than 3 years up to
40 kg in weight, the dose is 50 mg/kg once up to a total dose of
2 g.
Trichomoniasis
-
Tindamax is recommended as one of the drugs of choice for the
treatment of trichomoniasis by the CDC. Tindamax has
demonstrated cure rates of 92 to 100 percent in both women and
men.
-
Dose:
The dose in adults is 2 g x 1 dose with
food.
For children older than 3 years up to
40 kg in weight, the dose is 50mg/kg x1 up to a total dose of 2
g.
Amebiasis and amebic
liver abscess caused by E. histolytica
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The Transderm Scōp
System (Ch. 4) is a circular flat patch that delivers 1.0 mg of
scopolamine at a constant rate over 3 days. Because of its prolonged
action, it is especially useful for seasickness. Travelers may want to
try it for a few days before departure to identify any adverse effects.
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Because
of widespread bacterial resistance
TMP/SMX (Bactrim,
Septra, co-trimoxazole) is now considered a last-choice drug for
treating most cases of travelers' diarrhea.
-
The drug remains
effective, however, for treating
cyclosporiosis, a parasitic disease
that causes watery diarrhea.
Cyclosporiosis is
most endemic
in Haiti, Nepal, and Peru,
but also occurs in other developing countries.
-
Adult dosage: One
double-strength tablet every 12 hours for 7 days.
-
Child dosage: 8 mg/kg trimethoprim and 40 mg/kg sulfamethoxazole per 24
hours, given in 2 divided doses every 12 hours.
Other uses:
-
Treatment of skin infections caused
by methicillin-resistant Staph. aureus (MRSA). For this purpose, TMP/SMX is
often combined, in the absence of culture results, with a cephalosporin, such as cephalexin,
to cover possible beta-hemollytic strep infection.
-
Treatment of brucellosis: Adjunctive therapy, with gentamicin,
in treating brucellosis in children <8 y; used as monotherapy or
combined with rifampin or gentamicin to treat brucellosis in
pregnant females.
-
Treatment of urinary tract infections. One double-strength
tablets 2x daily. A 3-day course is usually sufficient.
TMP/SMX
is also prescribed for the treatment of Pneumocystis jirovecii pneumonia
(a yeart-like fungus - formerly called Pneumocystis carinii
pneumonia), and for prevention
of this type of pneumonia in people with HIV or other causes of
weakened immune systems.
IV
Dosage: 15 mg of trimethoprim component/kg/d in 3 divided doses
x 21 days (20 mL of IV solution in 250 mL of D5W IVPB q8h) [solution
for injection: 80/400 mg/5 mL]
Oral Dosage: 2 double-strength tablets 3x daily for 21 days.
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©2008 Travel Medicine, Inc. |
