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DPDx is an education resource designed for health professionals and laboratory scientists. For an overview including prevention and control visit www.cdc.gov/parasites/toxoplasmosis.

Toxoplasmosis

[Toxoplasma gondii]

Treatment Information

Treatment of immunocompetent adults with lymphadenopathic toxoplasmosis is rarely indicated; this form of the disease is usually self-limited. If visceral disease is clinically evident or symptoms are severe or persistent, treatment may be indicated for 2 to 4 weeks. Treatment for ocular diseases should be based on a complete ophthalmologic evaluation. The decision to treat ocular disease is dependent on numerous parameters including acuteness of the lesion, degree if inflamation, visual acuity, and lesion size, location, and persistance (for example, "classic therapy" for ocular toxoplasmosis, adults: pyrimethamine 100 mg for 1 day as a loading dose, then 25 to 50 mg per day, plus sulfadiazine 1 gram four times per day, plus folinic acid (leucovorin) 5-25 mg with each dose of pyrimethamine; pediatric dose: pyrimethamine 2 mg/kg first day then 1 mg/kg each day, plus sulfadiazine 50 mg/kg two times per day, plus folinic acid (leucovorin) 7.5 mg per day) for 4 to 6 weeks followed by reevaluation of the patient's condition. Leucovorin protects the bone marrow from the toxic effects of pyrimethamine. If the patient has a hypersensitivity reaction to sulfa drugs, pyrimethamine plus clindamycin can be used instead. The fixed combination of trimethoprim with sulfamethoxazole has been used as an alternative, as well as other drugs such as atovaquone and pyrimethamine plus azithromycin, which have not been extensively studied (see: Montoya JG, Boothroyd JC, Kovacs JA. Toxoplasma gondii in Mandell, Douglas, and Bennett's Principles and Preactice of Infectious Diseases, 7th, Edition, 2010. Mandell GL, Bennett JE, Dolin R, Eds. Churchill Livingstone Elsevier, Philadelphia, PA.; and de-la-Torre A, Stanford M, Curi A, Jaffe GJ, Gomez-Marin JE. Therapy for ocular toxoplasmosis. Ocul Immunol Inflamm. 2011;19:314-20. Corticosteroids are sometimes prescribed in addition to antiparasitic agents.

Management of maternal and fetal infection varies depending on the treatment center. In general, spiramycin is recommended (for the first and early second trimesters) or pyrimethamine/sulfadiazine and leucovorin (for late second and third trimesters) for women with acute T. gondii infection diagnosed at a reference laboratory during gestation. PCR is often performed on the amniotic fluid at 18 gestation weeks to determine if the infant is infected. If the infant is likely to be infected, then treatment with drugs such as pyrimethamine, sulfadiazine, and leucovorin is typical. Congenitally infected newborns are generally treated with pyrimethamine, a sulfonamide, and leucovorin for 1 year (see Montoya JG, Liesenfeld O. Toxoplasmosis. Lancet. 2004 Jun 12;363:1965-1976; for additional information regarding management in pregnant women, see Montoya JG, Remington JS. Management of Toxoplasma gondii infection in pregnancy. Clin Infect Dis 2008;47:554-566).

Persons with AIDS who develop active toxoplasmosis (usually toxoplasmic enchephalitis) need treatment that must be taken until a significant immunologic improvement is achieved as a result of antiretroviral therapy. Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. (April 10, 2009 / 58(RR04);1-198).

More on: Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents.

More on: Guidelines for the Prevention and Treatment of Opportunistic Infection in HIV-Exposed and HIV-Infected Children.

Pyrimethamine

Pyrimethamine is available for human use in the United States.

Note on Treatment in Pregnancy

Pyrimethamine is in pregnancy category C. Data on the use of pyrimethamine in pregnant women are limited. Pyrimethamine is commonly used in combination with sulfadiazine and folinic acid for treatment of fetal toxoplasmosis during the 2nd and 3rd trimesters. In malaria prevention interventions for which the World Health Organization (WHO) has determined that the benefit of treatment outweighs the risk, WHO allows use of pyrimethamine in combination with sulfadoxine in the 2nd and 3rd trimesters. Available evidence suggests avoiding pyrimethamine during the 1st trimester and supplementing pyrimethamine with folinic acid in pregnant women.

Pregnancy Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal, or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.

Note on Treatment During Lactation

Pyrimethamine is excreted in breast milk. Both the American Academy of Pediatrics and the WHO classify pyrimethamine to be compatible with breast-feeding. Pyrimethamine when used in combination with other drugs should be used with caution in breast-feeding women.

Note on Treatment in Pediatric Patients

The safety of pyrimethamine in children has not been established. In malaria prevention interventions for which the WHO has determined that the benefit of treatment outweighs the risk, WHO allows use of pyrimethamine in combination with sulfadoxine in children during the first year of life. Pyrimethamine is listed as an antipneumocystosis and antitoxoplasmosis medicine on the WHO Model List of Essential Medicines for Children, intended for the use of children up to 12 years of age.

Sulfadiazine

Sulfadiazine is available for human use in the United States.

Note on Treatment in Pregnancy

Sulfadiazine is in pregnancy category C. Data on the use of sulfadiazine in pregnant women are limited. Available evidence suggests avoiding sulfonamides after week 32 of pregnancy. Sulfadiazine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Pregnancy Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal, or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.

Note on Treatment During Lactation

Sulfadiazine is excreted in breast milk. The World Health Organization (WHO) recommends avoiding breastfeeding with sulfadiazine treatment. Sulfadiazine is contraindicated for use during lactation.

Note on Treatment in Pediatric Patients

The safety of sulfadiazine in children has not been established. Use in children age 2 months and younger is contraindicated unless used in the treatment of congenital toxoplasmosis. Sulfadiazine is listed as an antipneumocystosis and antitoxoplasmosis medicine on the WHO Model List of Essential Medicines for Children, intended for the use of children up to 12 years of age.

Clindamycin

Clindamycin is available for human use in the United States.

Note on Treatment in Pregnancy

Clindamycin is in pregnancy category B. Data on the use of clindamycin in pregnant women are limited, although no congenital anomalies have been reported. Clindamycin may be used during pregnancy in those patients who will clearly benefit from the drug.

Pregnancy Category B: Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters).

Note on Treatment During Lactation

Clindamycin is excreted in breast milk. The American Academy of Pediatrics classifies clindamycin as usually compatible with breastfeeding.

Note on Treatment in Pediatric Patients

The parenteral form of clindamycin contains benzyl alcohol, which has been associated with a fatal "gasping syndrome" in premature infants.

Trimethoprim–sulfamethoxazole

Trimethoprim–sulfamethoxazole (TMP–SMX) is available for human use in the United States.

Note on Treatment in Pregnancy

Trimethoprim–sulfamethoxazole (TMP–SMX) is in pregnancy category C. TMP–SMX should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. TMP-SMX should be avoided near-term because of the potential for hyperbilirubinemia and kernicterus in the newborn.

Pregnancy Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal, or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.

Note on Treatment During Lactation

Trimethoprim–sulfamethoxazole (TMP–SMX) is excreted in breast milk. TMP–SMX generally is compatible with breastfeeding of healthy, full-term infants after the newborn period. However, TMP-SMX generally should be avoided by women when nursing infants who are premature, jaundiced, ill, or stressed, or who have glucose-6-phosphate dehydrogenase deficiency.

Note on Treatment in Pediatric Patients

The safety of trimethoprim–sulfamethoxazole (TMP–SMX) in children has not been systematically evaluated. Use in children less than 2 months of age generally is not recommended.

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This information is provided as an informational resource for licensed health care providers as guidance only. It is not intended as a substitute for professional judgment.

 
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  • Page last reviewed November 29, 2013
  • Page last updated November 29, 2013
  • Content source: Global Health - Division of Parasitic Diseases and Malaria
  • Notice: Linking to a non-federal site does not constitute an endorsement by HHS, CDC or any of its employees of the sponsors or the information and products presented on the site.
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