Giardia lamblia is both the most common intestinal parasite in the United States and a frequent cause of diarrheal illness throughout the world. In spite of its recognition as an important human pathogen, there have been relatively few agents used in therapy. This paper discusses each class of drugs used in treatment, along with their mechanism of action, in vitro and clinical efficacy, and side effects and contraindications. Recommendations are made for the preferred treatment in different clinical situations. The greatest clinical experience is with the nitroimidazole drugs, i.e., metronidazole, tinidazole, and ornidazole, which are highly effective. A 5- to 7-day course of metronidazole can be expected to cure over 90% of individuals, and a single dose of tinidazole or ornidazole will cure a similar number. Quinacrine, which is no longer produced in the United States, has excellent efficacy but may be poorly tolerated, especially in children. Furazolidone is an effective alternative but must be administered four times a day for 7 to 10 days. Paromomycin may be used during early pregnancy, because it is not systematically absorbed, but it is not always effective. Patients who have resistant infection can usually be cured by a prolonged course of treatment with a combination of a nitroimidazole with quinacrine.

/pdf/treatment-of-giardiasis-1cicamizr8.pdf

Treatment of Giardiasis

Background 
Metronidazole is the most commonly used drug for the treatment of giardiasis in humans. In spite of its therapeutic efficacy for giardiasis, low patient compliance, especially in children, side effects, and the emergence of metronidazole-resistant strains may restrict its use. Albendazole has been used to treat Giardia duodenalis infections in recent years. However, efficacy studies in vivo and in vitro have produced diverse results as to its effectiveness. A moderately benign side effect profile, combined with established efficacy against many helminths, renders it promising for treatment of giardiasis in humans.


Methodology and Principal Findings 
We performed a search in the PubMed, Scopus, EMBASE, the ISI Web of Science, LILIACS, and Cochrane Controlled Trials Register for trials published before February 2010 as well as in references of relevant research and review articles. Eight randomized clinical trials (including 900 patients) comparing the effectiveness of albendazole with that of metronidazole were included in meta-analysis. After extracting and validating the data, the pooled risk ratio (RR) was calculated using an inverse-variance random-effects model. Albendazole was found to be equally as effective as metronidazole in the treatment of giardiasis in humans (RR 0.97; 95% CI, 0.93, 1.01). In addition, safety analysis suggested that patients treated with albendazole had a lower risk of adverse effects compared with those who received metronidazole (RR 0.36; 95% CI, 0.10, 1.34), but limitations of the sample size precluded a definite conclusion.


Conclusions/Significance 
The effectiveness of albendazole, when given as a single dose of 400 mg/day for 5 days, was comparable to that of metronidazole. Patients treated with albendazole tended to have fewer side effects compared with those who took metronidazole. Given the safety, effectiveness, and low costs of albendazole, this drug could be potentially used as an alternative and/or a replacement for the existing metronidazole therapy protocols in the treatment of giardiasis in humans.

/pdf/a-meta-analysis-of-the-effectiveness-of-albendazole-compared-naucbzis3d.pdf

A meta-analysis of the effectiveness of albendazole compared with metronidazole as treatments for infections with Giardia duodenalis.

Treatment of gastrointestinal infections

Giardia intestinalis can develop resistance to albendazole, although the molecular mechanism is not understood. The aim of this study was to investigate the differences and permanent mutation in the β-giardin gene of G. intestinalis strains: sensitive, resistant, or recovered-resistance to albendazole. The β-giardin gene was amplified by nested polymerase chain reaction. The IC50 values varied from 0.29 to 0.38 μg/mL for strains sensitive to albendazole. For resistant strains, the IC50 range was 1.31–2.12 μg/mL. Recovered-sensitivity albendazole strains’ IC50 values were 0.33–0.49 μg/mL, and for strains with recovered-resistance, the IC50 was 1.42–2.74 μg/mL. β-giardin amplicon (720 bp) was sequenced and analysis sequence revealed several amino acid mutations from resistant and recovered-sensitive strains of G. intestinalis. Most of the mutations were located in the ROD domain of β-giardin with a change from the sequence “TIARERA” in sensitive strains instead “IDRPRE” in resistant strains. A comparative sequence analysis in resistant, recovered-sensitive, and resistant-recovered strains revealed permanent mutation. This is the first report of combinatorial serine–proline–arginine repeats in the ROD domain of β-giardin, whereas such repeats have been reported previously in the HEAD domain of SF-assemblin proteins. This is the first time that the resistance to albendazole correlates with genetics but it is not necessarily caused by mutations in the β-giardin gene of G. intestinalis.

Changes in β-giardin sequence of Giardia intestinalis sensitive and resistant to albendazole strains

Background:Albendazole (ABZ) is a benzimidazole carbamate compound currently in use for human medical practice against enterobiasis and soil-transmitted helminthiasis (STH); However, its spectrum of activity is broad and goes beyond these infections.Objective:This study compares the efficacy and safety of ABZ versus metronidazole (MTZ) in human giardiasis.Research design and methods:A randomized, double-blind, clinical trial was carried out at the Centre of Hygiene, Epidemiology and Microbiology in Matanzas City, Cuba. Adult patients with confirmed symptomatic G. duodenalis mono-infection were randomly assigned to receive either ABZ [400 mg daily (n = 75)] or MTZ [250 mg t.i.d. (n = 75)], both for 5 days. Follow-up fecal samples were obtained at 3, 5, 7 days after treatment end.Results:The efficacy was similar for both treatment groups: ABZ (82.6%) and MTZ (85.3%); p > 0.05. Side-effects including bitter taste, headache, vomiting and dizziness were significantly higher in the MTZ group. Abdominal ...

Albendazole versus metronidazole in the treatment of adult giardiasis: a randomized, double-blind, clinical trial

An open, randomized study was carried out with 100 children to compare the efficacy and security of albendazole and metronidazole to eradicate Giardia lamblia. We included 100 patients in primary school age with giardiasis confirmed by parasitoscopic test who had not received treatment during the 2 previous months. A complete clinical study was performed. By using an aleatory code, the children were distributed in 2 groups: A and B. The clinical data was corroborated and the following tests were made: cell blood count, blood chemistry, direct and concentrated coproparasitoscopic study. Both groups were given an antiparasite treatment consisting of albendazole for group A or metronidazole for group B. Clinical, parasitological and blood controls were conducted before, during and after the treatment. A therapeutic efficacy of 94% and 98% for group A and B, respectively, was found. We concluded that albendazole and metronidazole are equally effective in a 5 days treatment period, but some undesirable effects may occur with metronidazole.

Randomized study comparing the safety and efficacy of albendazole and metronidazole in the treatment of giardiasis in children

Out of total 475 subjects’ female and male were 292 (61.5%) and 183 (38.5%) respectively. This table also displays out of 475 only 257(54.1%) samples yield bacterial isolates, on the other hand total 218(45.9%) samples fails to demonstrate growth of any bacteria. Shashibhushan et al.8 reported 122 (76.3%) males and 38 (23.7%) females with a male: female ratio of 61:19. Sputum culture positivity was observed in 78 cases (48.7%). Patel et al.9 observed culture was positive was found in 41 (82%) patients. Abraham et al.10 observed out of which 103 (42.9%) were positive for pathogenic bacteria and 137 (57.1%) were normal flora. Out of 240 patients with acute exacerbation of COPD, 184 (76.67%) were males and 56 (23.3%) were females. In this study observed that the study population of 257 consecutive patients with bacterial comprised 166 men (64.6%) and 91 women (35.4%), ranging in age from 37 years to 80 years, mean 76.0 [standard deviation (SD) 20.37] years. Most frequent distribution of the isolates in the sputum was found in the age group 49 to 60 years. Out of total 257 isolates, 137 was belongs to this age group of which male and female were 88 and 49 respectively. Shashibhushan et al.8 reported the mean age of patients was 63.18 years (40-81) which comprises of 84% of males and 16 % of female patients. Maximum numbers of patients were in the age group of 6170 years. Sharma et al.11 also reported maximum patients (32.05%) belonging to the age group of 51–60 years. Rashid and Ahmed3 the age of the patients ranged from 46−88 years with most of the patients (56%) in the age group 55−65 years. Abraham et al.10 reported maximum number (178) belonged to the age group of 60-79 years. Common organisms responsible for AECOPD, like S. pneumoniae, H.influenzae and M.catarrhalis, were sensitive to commonly used antibiotics, fluoroquinolones.cephalosporin, amino glycosides and piperacillin-tazobactam. Sharma et al.11 In this study observed that the majority (45.5%) of the patients had growth of Klebsiella pneumoniae in followed by Pseudomonas 76(29.6%), E. coli 32(12.5%), Stapylococcus aureus 16(6.2%), Acinetobacter 8(3.1%) and Streptococcus 8(3.1%). Shashibhushan et al.8 reported the commonest pathogenic bacteria isolated in sputum culture was Streptococcus pneumoniae 42 (42%), followed by Pseudomonas aeuroginosa 23 (23%), Klebsiella 15 (15%), E coli 12 (12%), gram-negative non fermenting bacteria (GNNF) 7 (7%) and Citrobacter 1 (1%). But other Indian study has reported different strain Pseudomonas aeruginosa12. Madhavi et al.13 had found Klebsiella pneumonia was the most common organism. Rashid and Ahmed3 reported Bacteriological profile: Klebsiella pneumoniae were the commonest (16 cases) bacteria isolated followed by Staphylococcus aureus (9 cases). Streptococcus pneumoniae was isolated in seven cases and Pseudomonas aeruginosa in three cases. Majumder et al.14 observed among 198 culture positive samples, E. coli was ranked highest 171 (86%). Growth of Klebsiella pneumonia and Enterococcus was

Bacteriological Profile of Suspected Neonatal Septicaemia and Its Relationship with Selected Risk Factors

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Randomized study comparing the safety and efficacy of albendazole and metronidazole in the treatment of giardiasis in children

Bacteriological Profile of Suspected Neonatal Septicaemia and Its Relationship with Selected Risk Factors