infectious diseases
Leishmaniasis
Treatment of Leishmaniasis
Drug therapy depends on the clinical syndrome and other factors For cutaneous infection, topical treatment,sodium stibogluconateinjection or topicalparomomycinoutside the US or heat therapy or cryotherapy For systemic treatment of cutaneous, mucosal, or visceral leishmaniasis, liposomal amphotericin IV ormiltefosineorally Alternatively,amphotericin Bdeoxycholate IV or pentavalent antimonials (sodium stibogluconate, meglumine antimoniate) IV or IM if the infectingLeishmaniaspecies is likely to be susceptible Treatment of leishmaniasis is complicated. The therapeutic approach depends on the following: Clinical syndrome InfectingLeishmaniaspecies Geographic location of acquisition Organism's likelihood of susceptibility to antileishmanial drugs Immune status of the host Detailed recommendations for treatment are available ( Treatment references , Sodium stibogluconateis no longer available from the Centers for Disease Control and Prevention (seeCenters for Disease Control and Prevention: Infectious Diseases Laboratories). Treatment of cutaneous leishmaniasis may be topical or systemic, depending on the lesion and organism. If a lesion is small, spontaneously healing, and not caused by aLeishmaniaspecies associated with mucosal leishmaniasis, it can be closely followed, rather than treated. Topical treatmentis an option for small, uncomplicated lesions. Intralesional injection ofsodium stibogluconatehas been used for many years for simple cutaneous leishmaniasis in Europe and Asia; it is not currently available in the US for intralesional use. Other topical options include heat therapy, which requires a specialized system for administration, and cryotherapy; both can be painful and are practical only when used to treat small lesions. In addition, topicalparomomycinis used outside the US as an ointment that contains 15%paromomycinand 12% methylbenzethonium chloride in soft white paraffin. Systemic therapyis used in patients who have the following: Infection byL. braziliensisor related organisms associated with mucosal leishmaniasis Complex cutaneous leishmaniasis with multiple, large, widespread, or disfiguring lesions Compromised cell-mediated immunity deoxycholate are typically given in the regimens used for Visceral leishmaniasis . Miltefosine, which has the advantage of oral administration, can be effective for cutaneous leishmaniasis, particularly when caused byLeishmania braziliensis,Leishmania guyanensis, andLeishmania panamensis.Miltefosineis dosed by body weight: patients 30 to 44 kg, 50 mg orally twice a day for 28 days; ≥ 45 kg, 50 mg orally 3 times a day for 28 days. Adverse effects include nausea, vomiting, transient elevations in aminotransferases, and dizziness.Miltefosineis contraindicated during pregnancy; women of childbearing age who are taking this drug must use effective birth control measures. Pentavalent antimonials (sodium stibogluconateor meglumine antimoniate) should be used only if the infectingLeishmaniaspecies is likely to be susceptible. Meglumine antimoniate (a pentavalent antimonial) is used in Latin America. Doses of both are based on their pentavalent antimony content—20 mg/kg IV (slow infusion required) or IM once a day for 20 days. Adverse effects include nausea, vomiting, malaise, elevated amylase and/or liver enzymes, and cardiotoxicity (arrhythmias, myocardial depression, heart failure, ECG changes, cardiac arrest). The incidence of adverse effects increases with age. The drug is stopped if patients develop cardiotoxicity. Alternatives include azoles (eg,fluconazole).Fluconazole200 mg orally once a day for 6 weeks is commonly ineffective, but success has been reported with higher daily doses in some areas. Diffuse cutaneous leishmaniasis is relatively resistant to treatment. The optimal treatment is uncertain. Recent studies suggest that liposomalamphotericin Bwith a cumulative dose ranging from 20 to 60 mg/kg ormiltefosinedosed by body weight: patients 30 to 44 kg, 50 mg orally twice a day for 28 days; ≥ 45 kg, 50 mg orally 3 times a day for 28 days are often effective, but data are limited. Adverse effects ofmiltefosineinclude nausea, vomiting, transient elevations in aminotransferases, and dizziness; the drug is contraindicated during pregnancy so women of childbearing age who are taking this drug must use effective birth control measures. Historically, pentavalent antimonials have been used in Latin America. Another alternative isamphotericin Bdeoxycholate 0.5 to 1.0 mg/kg IV once a day or every other day for a total dose of 20 to 45 mg/kg. Reconstructive surgery may be required if mucosal leishmaniasis grossly distorts the nose or palate, but surgery should be delayed for 12 months after successful chemotherapy to avoid losing grafts because of relapses. Liposomalamphotericin Bandmiltefosineare approved by the US Food and Drug Administration for treatment of visceral leishmaniasis; other lipid-associated amphotericin preparations may be effective but have been less well studied. Dosage of liposomalamphotericin Bis For immunocompetent patients: 3 mg/kg IV once a day for 5 days and then once a day on days 14 and 21 (total dose of 21 mg/kg) For patients with AIDS or other immunocompromising conditions: 4 mg/kg IV once a day on days 1 to 5, 10, 17, 24, 31, and 38 (total dose of 40 mg/kg) Miltefosineorally, dosed by body weight: patients 30 to 44 kg, 50 mg twice a day for 28 days or for patients ≥ 45 kg, 50 mg 3 times a day for 28 days can be used to treat immunocompetent patients who acquiredL. donovaniin India or adjacent areas of South Asia, who are > 12 years of age, who weigh > 30 kg, and who are not pregnant or breastfeeding. Pentavalent antimonials can be used to treat visceral leishmaniasis acquired in Latin America or other areas of the world where the infection is not resistant to these drugs. Dosage is 20 mg/kg (based on the antimony content) IV or IM once a day for 28 days. An alternative isamphotericin Bdeoxycholate 1 mg/kg IV once a day for 15 to 20 days or every other day for up to 8 weeks. Relapses are common among patients with AIDS or other immunocompromising conditions. Antiretroviral drugs can help restore immune function in those with AIDS, reducing the likelihood of relapse. Secondary prophylaxis with an antileishmanial drug may help prevent relapses in AIDS patients with CD4 counts < 200/mcL. Supportive measures (eg, adequate nutrition, transfusions, antibiotics for secondary bacterial infection) are often necessary for patients with visceral leishmaniasis. 1.Aronson N, Herwaldt BL, Libman M, et al: Diagnosis and treatment of leishmaniasis: Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH).Clin Infect Dis63 (12):e202-e264, 2016. doi: 10.1093/cid/ciw670 2.Centers for Disease Control and Prevention (CDC): Resources for Health Professionals: Treatment. 