Quinine-clindamycin

Parola P, Ranque S, Badiaga S, Niang M, Blin O, Charbit JJ, Delmont J, Brouqui P. Controlled trial of 3-day quinine-clindamycin treatment versus 7-day quinine treatment for adult travelers with uncomplicated falciparum malaria imported from the tropics. Antimicrob Agents Chemother 2001 45(3) 932-5. 

Quinine sulfate is appropriate first-line therapy for uncomplicated falciparum malaria except when the infection was transmitted in an area without documented chloroquine-resistant malaria. Quinine is commonly used with a second drug (most often doxycycline or, in children, clindamycin) to shorten quinine s duration of use (usually to 3 days) and limit toxicity. Quinine is less effective than chloroquine against other human malarias and is more toxic. Therefore, it is not used to treat infections with these parasites. 

Quinine is first-line therapy, in combination with clindamycin, in the treatment of infection with Babesia microti or other human babesial infections. 

Clindamycin (see Chapter 44) is slowly active against erythrocytic schizonts and can be used after treatment courses of quinine, quinidine, or artesunate in those for whom doxycycline is not recommended, such as children and pregnant women. Azithromycin (see Chapter 44) also has antimalarial activity and is now under study as an alternative chemoprophylactic drug. Antimalarial activity of fluoroquinolones has been demonstrated, but efficacy for the therapy or chemoprophylaxis of malaria has been suboptimal. 

Chloroquine-resistant Quinine Artemisinin derivatives Atovaquone-proguanil Mefloquine Pyrimethamine-sulfadoxine Antibacterials (e.g., clindamycin, doxycycline, sulfamethoxazole, or tetracycline] ... 

Babesia species Clindamycin, 600 mg 3 times daily for 7 days plus- Quinine, 650 mg for 7 days Atovaquoneor azithromycin... 

Human babesiosis has been traditionally treated with quinine plus clindamycin, a combination that has been compared with atovaquone plus azithromycin in a randomized, multicenter, unblinded study (7). The treatments... 

In a prospective, open, randomized trial clindamycin (600 mg tds) and quinine (650 mg tds) were compared with atovaquone (750 mg bd) plus azithromycin (500 mg on day 1 followed by 250 mg/day) in 58 patients with non-life-threatening babesiosis (3). Bacterial response was complete 3 months after the end of treatment. Adverse effects were reported by 72% of those who received clindamycin and quinine compared with 15% of those who received atovaquone and azithromycin. The most common adverse effects with clindamycin and quinine were tinnitus (39%), diarrhea (33%), and impaired hearing (28%) the symptoms had resolved in 73% of the patients assigned to clindamycin/quinine 3 months after the start of therapy and in 100% after 6 months. 

A double-blind, placebo-controlled trial of a 3-day combination regimen of quinine (8 mg/kg tds) and clindamycin (5 mg/kg tds) (n — 53) versus 7-day quinine (8 mg/kg tds intravenously for 3 days, then orally n = 55) to treat uncomplicated imported falciparum malaria showed no significant differences in the parasite and fever clearance... 

In P. falciparum (chloroquine-resistant) infections, a dose of 750 mg mefloquine followed by 500 mg 12 hours later is recommended. The pediatric dose of mefloquine is 15 mg/kg (<45 kg) followed by 10 mg/kg 8 to 12 hours later.Intravenous quinidine gluconate followed by oral quinine should be administered for severe illness, as already indicated.A second drug needs to be administered in chloroquine-resistant P. falciparum, and this second drug should follow the oral quinidine regimen either a single dose of three tablets of pyrimethamine-sulfadoxine (Fansidar) on the last day of intravenous quinidine or clindamycin 900 mg three times daily for 3 to 5 days. An alternative oral treatment for chloroquine-resistant P falciparum infection in adults, especially in those with a history of seizures or psychiatric disorders, is the combination of atovaquone 250 mg and proguanil 100 mg (Malarone) (4 tablets daily... 

Treatment quinine +/- either doxycycline or clindamycin or pyrimethamine... 

Quinine (650 mg every 8 honrs for 5 to 7 days) is indicated for the treatment of chloroquine-resistant falciparum malaria, either alone, with pyrimethamine and a sulfonamide, or with a tetracycline. It is also considered as an alternative therapy for chloroquine-sensitive strains of P. falciparum, P. malariae, P. ovale, andP vivax. Mefloquine and clindamycin may also be nsed with quinine, depending on the geographical location in which the malaria was acquired. 

Pyrimethamine-sulfadoxine (fansidar). This combination is available for oral use only in tablets containing 25 mg pyrimethamine and 500 mg sulfadoxine. One dose is taken by mouth on the last day of quinine sulfate therapy Adults take 3 tablets children 5-10 kg, 0.5 tablet 11-14 kg, 0.75 tablet 15-20 kg, 1 tablet 21-30 kg, 1.5 tablets 31 0 kg, 2 tablets 41-50 kg, 2.5 tablets over 50 kg, 3 tablets. Owing to extensive drug resistance, pyrimethamine-sulfadoxine should be used as an adjunct treatment primarily in young children or women who are not able to tolerate clindamycin. 

Babesiosis is a tick-bome zoonosis caused by parasites that invade erythrocytes, producing a febrile illness, hemolysis, and hemoglobinuria. Infection usually is self-limiting but can be severe or even fatal in asplenic or severely immunocompromised individuals. Standard therapy is a combination of clindamycin and quinine, but azithromycin plus atovaquone was as effective with... 

Quinine sulfate is the standard drug for oral treatment of acute attacks of malaria due to chloroquine-resistant P falciparum. It should be used in combination with one or more other antimalarial drugs such as doxycycUne, clindamycin, or pyrimethamine plus sulfadiazine. The answer is (E). 

In a meta-analysis of the effectiveness of clindamycin plus quinine for the treatment of falciparum malaria, two patients reported watery diarrhoea secondary to C. difficile [87 ]. 

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