Clinical presentation and diagnosis Pharmacologic Therapy

O All symptomatic adults and children over the age of 8 years with giardiasis should be treated with metronidazole 250 mg three times daily for 7 days, or tinidazole 2 g

as a single dose, or nitazoxanide (Alina) 500 mg twice daily for 3 days. , The pediatric dose of metronidazole is 15 mg/kg/day three times daily for 7 days. Alternative drugs include furazolidone 100 mg four times daily or paromomycin 25 to 35 mg/kg/day in divided doses daily for 7 days. Paromomycin may be used in pregnancy instead of metronidazole. Pediatric patients can also be treated with suspensions of either furazolidone 6 mg/kg/day in four divided doses for 7 days.

Clinical Presentation and Diagnosis of Giardiasis Acute Onset

• Diarrhea, cramp-like abdominal pain, bloating, and flatulence

• Malaise, anorexia, nausea, and belching Chronic Symptoms

• Diarrhea: Foul-smelling, copious, light-colored and greasy stools

• Weight loss, steatorrhea, and vitamin B12 and fat-soluble vitamin deficiencies

• Constipation alternating with diarrhea Diagnosis

• Diagnosis is made by examination of fresh stool or a preserved specimen during acute diarrheal phase

• Fresh stool may show trophozoites while preserved specimens yield cysts. (Note: stool for ova may show the presence of other parasites [e.g., Cryptosporidium par-vum, E. histolytica, or E. hartmanni]; multiple stool samples may be needed.)

• Even though stool examination for ova and parasites has remained the major means of diagnosis, other diagnostic tests include enzyme-linked immunosorbent assay (ELISA), which is considered to be between 85% and 98% sensitive and almost 100% specific (ProSpec T, Giardia Microplate Assay, Remel, Lenexa, KS).

Quinacrine 100 mg three times in adults or 5 mg/kg/day in pediatric patients for 5 to 7 days, is available from a specialized pharmacy (e.g., Ponorama Compounding Pharmacy).12

Patient Care and Monitoring: Giardiasis

• Metronidazole produces cure rates between 85% and 95%.

• Diarrhea will cease within a few days, although in some patients it may take 1 to 2 weeks.

• Cyst excretion will cease within days.

• Intestinal dysfunction (manifested as increased transit time) and radiologic changes primarily due to chronic infection may take months to resolve.

• Patients who fail therapy with metronidazole should receive a second course with either metronidazole or an alternative agent; nitazoxanide has been shown to be effective in resistant giardiasis.

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