Materiały źródłowe

• #1 Treatment of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/treatment/index.html

  Most people with healthy immune systems recover from toxoplasmosis without treatment. […] Talk to your healthcare provider about treatment options if you are pregnant or immunocompromised (have a weakened immune system). […] If you are sick and need treatment, a healthcare provider can treat you with a combination of drugs such as pyrimethamine and sulfadiazine, plus folinic acid. […] Healthcare providers can treat toxoplasmosis in pregnant women, newborns, and infants. […] If you have ocular toxoplasmosis (an eye infection from the Toxoplasma parasite), an ophthalmologist (eye doctor) can treat you. […] Healthcare providers will treat people who are immunocompromised until their health improves. Some people, such as those with HIV, may need to take drugs for the rest of their lives, or as long as they are immunosuppressed.

• #2 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Most people with healthy immune systems recover from toxoplasmosis without treatment. […] Drugs are available for those who require treatment. […] Currently recommended treatment drugs for toxoplasmosis target the tachyzoite stage of the parasite and do not eradicate encysted parasites in the tissues. […] Pyrimethamine, considered the most effective drug against toxoplasmosis, is a standard component of therapy. […] A second drug, such as sulfadiazine or clindamycin (if the patient has a hypersensitivity reaction to sulfa drugs), should also be included. […] 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.

• #3 Toxoplasmosis | Better Health Channel

  https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/toxoplasmosis

  A healthy person does not usually require treatment for toxoplasmosis, as symptoms are mild and usually disappear within a few weeks. […] Treatment of toxoplasmosis is often unnecessary. The infection is diagnosed with a simple blood test that checks for the presence of specific antibodies. A healthy person who is not pregnant and becomes infected does not require treatment. Symptoms, if any, are usually mild and disappear after a few weeks. […] For pregnant women and those with compromised immune systems, such as those in the later stages of human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), medications including antibiotics may be prescribed.

• #4 Toxoplasmosis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK563286/

  The main goal of treatment is to limit parasite multiplication during active infection. Prophylaxis with trimethoprim-sulfamethoxazole can prevent acute infection in those who are immunosuppressed and should be considered in patients who need it according to local or international guidelines. Treatment is indicated in immunocompetent individuals with severe or prolonged symptoms and all those who are immunocompromised. […] In immunosuppressed individuals, it is essential to ascertain which patients need prophylactic medication to avoid reactivation of toxoplasmosis. Reactivation of latent cysts is the primary mechanism of toxoplasmosis following HSCT and SOT and when patients with HIV/AIDS have a CD4 lymphocyte count of less than 100 cells/L. The preferred regimen for prophylaxis in these patients is trimethoprim-sulfamethoxazole.

• #5 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  Currently recommended drugs in the treatment of toxoplasmosis act primarily against the tachyzoite form of T gondii; thus, they do not eradicate the encysted form (bradyzoite). Pyrimethamine is the most effective agent and is included in most drug regimens. Leucovorin (ie, folinic acid) should be administered concomitantly to prevent bone marrow suppression. Unless circumstances preclude using more than 1 drug, a second drug (eg, sulfadiazine, clindamycin) should be added. […] The most effective available therapeutic combination is pyrimethamine plus sulfadiazine or trisulfapyrimidines (eg, a combination of sulfamerazine, sulfamethazine, and sulfapyrazine). These agents are active against tachyzoites and are synergistic when used in combination. […] A study shows that combination of the immunomodulatory agents, levamisole and Echinacea, and pyrimethamine plus sulfadiazine for the treatment of toxoplasmosis increases the survival of mice.

• #6 How to Diagnose & Treat Ocular Toxoplasmosis

  https://www.reviewofophthalmology.com/article/how-to-diagnose-treat-ocular-toxoplasmosis

  Toxoplasmosis is one of the most frequently identifiable causes of uveitis worldwide. […] The goal of treatment is to arrest the multiplication of the parasite during the active period of retinochoroiditis and to minimize damage to the retina and optic nerve. […] Patients with the following characteristics are considered by most to be appropriate treatment candidates: optic nerve involvement either direct or within two disc diameters; a lesion within the temporal arcades or threatening the arcade vessels; a large lesion with subretinal hemorrhage and/or serous retinal detachment regardless of location; severe vitreous inflammation; loss of more than two lines in visual acuity; persistent retinochoroidal inflammation for more than one month; toxoplasmic retinochoroiditis in the first year of life; a newborn diagnosed with congenital toxoplasmosis regardless of the presence or absence of ocular lesions; and any lesion in an immunocompromised host.

• #7 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Most people with healthy immune systems recover from toxoplasmosis without treatment. […] Drugs are available for those who require treatment. […] Currently recommended treatment drugs for toxoplasmosis target the tachyzoite stage of the parasite and do not eradicate encysted parasites in the tissues. […] Pyrimethamine, considered the most effective drug against toxoplasmosis, is a standard component of therapy. […] A second drug, such as sulfadiazine or clindamycin (if the patient has a hypersensitivity reaction to sulfa drugs), should also be included. […] 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.

• #8 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  Unfortunately, all drugs used in clinical practice are solely active against the tachyzoite stage of the parasite and do not demonstrate activity against cysts containing bradyzoites, the latent stage of the parasite. […] The rate of unacceptable adverse reactions, as well as the high pill burden associated with pyr-sulf, led to a quest for other therapeutic options. […] Initial, nonrandomized studies showed efficacy of clindamycin-based regimens, but the relapse rate was high for clindamycin-only maintenance therapy. […] A phase II randomized trial of pyr-sulf versus pyrimethamine-clindamycin involved 59 patients with TE. […] Based on these findings, it was concluded that pyrimethamine-clindamycin is as effective as pyr-sulf and can be used as an alternative regimen for the treatment of TE.

• #9 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  Primary Toxoplasma gondii infection is usually subclinical, but cervical lymphadenopathy or ocular disease can be present in some patients. […] The combination of pyrimethamine and sulfadiazine (pyr-sulf), targeting the active stage of the infection, is the current gold standard for treating toxoplasmosis, but failure rates remain significant. […] Although other regimens are available, including pyrimethamine in combination with clindamycin, atovaquone, clarithromycin, or azithromycin or monotherapy with trimethoprim-sulfamethoxazole (TMP-SMX) or atovaquone, none have been found to be superior to pyr-sulf, and no regimen is active against the latent stage of the infection. […] Furthermore, the efficacy of these regimens against ocular disease remains uncertain. […] In multiple studies, systematic screening for Toxoplasma infection during gestation, followed by treatment with spiramycin for acute maternal infections and with pyr-sulf for those with established fetal infection, has been shown to be effective at preventing vertical transmission and minimizing the severity of congenital toxoplasmosis (CT).

• #10 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  Currently recommended drugs in the treatment of toxoplasmosis act primarily against the tachyzoite form of T gondii; thus, they do not eradicate the encysted form (bradyzoite). Pyrimethamine is the most effective agent and is included in most drug regimens. Leucovorin (ie, folinic acid) should be administered concomitantly to prevent bone marrow suppression. Unless circumstances preclude using more than 1 drug, a second drug (eg, sulfadiazine, clindamycin) should be added. […] The most effective available therapeutic combination is pyrimethamine plus sulfadiazine or trisulfapyrimidines (eg, a combination of sulfamerazine, sulfamethazine, and sulfapyrazine). These agents are active against tachyzoites and are synergistic when used in combination. […] A study shows that combination of the immunomodulatory agents, levamisole and Echinacea, and pyrimethamine plus sulfadiazine for the treatment of toxoplasmosis increases the survival of mice.

• #11 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Most people with healthy immune systems recover from toxoplasmosis without treatment. […] Drugs are available for those who require treatment. […] Currently recommended treatment drugs for toxoplasmosis target the tachyzoite stage of the parasite and do not eradicate encysted parasites in the tissues. […] Pyrimethamine, considered the most effective drug against toxoplasmosis, is a standard component of therapy. […] A second drug, such as sulfadiazine or clindamycin (if the patient has a hypersensitivity reaction to sulfa drugs), should also be included. […] 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.

• #12 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  Despite significant progress in treating human disease, there is a strong impetus to develop novel therapeutics for both the acute and latent forms of the infection. […] Treatment of toxoplasmosis typically includes combinations of two antimicrobials, most often inhibitors of dihydrofolate reductase (DHFR) (pyrimethamine and trimethoprim) and dihydropteroate synthetase (sulfonamides, such as sulfadiazine, sulfamethoxazole, and sulfadoxine), which block folic acid synthesis. […] Pyrimethamine, a key DHFR inhibitor, appears to be the most effective drug against T. gondii and is the basis for effective regimens. […] These include pyrimethamine-sulfadiazine (pyr-sulf), the gold standard against which other regimens are measured, and pyrimethamine combined with clindamycin, atovaquone, clarithromycin, or azithromycin.

• #13 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  For many years, the initial therapy of choice for TE has been the combination of pyrimethamine plus sulfadiazine plus leucovorin. Pyrimethamine penetrates the brain parenchyma efficiently even in the absence of inflammation. Leucovorin reduces the likelihood of hematologic toxicities associated with pyrimethamine therapy. Pyrimethamine, however, has become extremely expensive and can be difficult to obtain in the United States. […] TMP-SMX has been used with increasing frequency as a preferred regimen, although large, randomized trials comparing TMP-SMX to pyrimethamine plus sulfadiazine have not been performed. In a small (77 patients) randomized trial, TMP-SMX was reported to be as effective and better tolerated than pyrimethamine-sulfadiazine. […] Clinical response to acute therapy occurs in ~90% of patients with TE within 14 days of initiating appropriate anti-Toxoplasma treatment. The reasons why some patients fail therapy are not clearly proven; whether such failures are due to poor adherence, other host factors, or antimicrobial resistance has not been well delineated. Acute therapy for TE should be continued for 6 weeks, if there is clinical and radiologic improvement. Longer courses may be necessary if clinical or radiologic disease is extensive or response is incomplete at 6 weeks. After completion of the acute therapy, all patients should be continued on chronic maintenance therapy as outlined below.

• #14 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  Currently recommended drugs in the treatment of toxoplasmosis act primarily against the tachyzoite form of T gondii; thus, they do not eradicate the encysted form (bradyzoite). Pyrimethamine is the most effective agent and is included in most drug regimens. Leucovorin (ie, folinic acid) should be administered concomitantly to prevent bone marrow suppression. Unless circumstances preclude using more than 1 drug, a second drug (eg, sulfadiazine, clindamycin) should be added. […] The most effective available therapeutic combination is pyrimethamine plus sulfadiazine or trisulfapyrimidines (eg, a combination of sulfamerazine, sulfamethazine, and sulfapyrazine). These agents are active against tachyzoites and are synergistic when used in combination. […] A study shows that combination of the immunomodulatory agents, levamisole and Echinacea, and pyrimethamine plus sulfadiazine for the treatment of toxoplasmosis increases the survival of mice.

• #15 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  The 6-week regimen is as follows: Pyrimethamine (100mg loading dose orally followed by 25-50 mg/day) plus sulfadiazine (2-4 g/day divided 4 times daily) OR Pyrimethamine (100-mg loading dose orally followed by 25-50 mg/day) plus clindamycin (300 mg orally 4 times daily). […] Consider steroids in patients with radiologic midline shift, clinical deterioration after 48 hours, or elevated intracranial pressure. […] The diagnosis of acute infection often is difficult to make during pregnancy, and the administration of empiric antimicrobial therapy is discouraged. […] Spiramycin appears to be somewhat more easily tolerated than pyrimethamine-sulfonamide. […] A dosing regimen for pregnant patients is as follows: Spiramycin 1 g orally every 8 hours. […] Patients with AIDS are treated with pyrimethamine 200 mg orally initially, followed by 50-75 mg/day orally plus folinic acid 10 mg/day orally plus sulfadiazine 4-8 g/day orally for as long as 6 weeks, followed by lifelong suppressive therapy or until immune reconstitution.

• #16 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Acute, self-limited disease in an immunocompetent, non-pregnant individual usually requires no treatment. Treatment is recommended if an individual presents with visceral disease or the symptoms are severe or persistent. […] TE is often treated empirically; evidence of clinical and radiographic response to 2 weeks of therapy supports the diagnosis. Preferred: treatment duration, 6 weeks: Pyrimethamine 200 mg PO once, then weight-based: 60 kg: pyrimethamine 50 mg PO daily + sulfadiazine 1000 mg PO q6hr + leucovorin 10-25 mg PO daily. 60 kg: pyrimethamine 75 mg PO daily + sulfadiazine 1500 mg PO q6hr + leucovorin 10-25 mg PO daily. […] Duration: If the response to therapy is slow or incomplete, 6 weeks may be required for initial therapy. Leucovorin (folinic acid) 10-25 mg PO daily reverses bone marrow suppression of pyrimethamine.

• #17 Toxoplasmosis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK563286/

  In cases of suspected T gondii infection, empirical therapy based on presumptive diagnosis is preferred rather than waiting for test results. The combination of pyrimethamine (200 mg loading dose followed by 50 mg daily for patients weighing less than 60 kg and 75 mg daily for patients who weigh more than 60 kg) and sulfadiazine (1000 mg 4 times a day for patients who weigh less than 60 kg and 1500 mg 4 times a day for patients who weigh more than 60 kg) is the preferred regimen for treatment. An alternative treatment can be trimethoprim-sulfamethoxazole. Initial therapy should be continued for 6 weeks and be followed by chronic maintenance therapy. Folic acid is usually added to the treatment regimen to prevent folic acid deficiency because sulfadiazine inhibits folic acid biosynthesis. In central nervous system and ocular toxoplasmosis, steroids can be added to the standard regimen to treat cerebral edema and ocular toxoplasmosis.

• #18 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Acute, self-limited disease in an immunocompetent, non-pregnant individual usually requires no treatment. Treatment is recommended if an individual presents with visceral disease or the symptoms are severe or persistent. […] TE is often treated empirically; evidence of clinical and radiographic response to 2 weeks of therapy supports the diagnosis. Preferred: treatment duration, 6 weeks: Pyrimethamine 200 mg PO once, then weight-based: 60 kg: pyrimethamine 50 mg PO daily + sulfadiazine 1000 mg PO q6hr + leucovorin 10-25 mg PO daily. 60 kg: pyrimethamine 75 mg PO daily + sulfadiazine 1500 mg PO q6hr + leucovorin 10-25 mg PO daily. […] Duration: If the response to therapy is slow or incomplete, 6 weeks may be required for initial therapy. Leucovorin (folinic acid) 10-25 mg PO daily reverses bone marrow suppression of pyrimethamine.

• #19 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  The 6-week regimen is as follows: Pyrimethamine (100mg loading dose orally followed by 25-50 mg/day) plus sulfadiazine (2-4 g/day divided 4 times daily) OR Pyrimethamine (100-mg loading dose orally followed by 25-50 mg/day) plus clindamycin (300 mg orally 4 times daily). […] Consider steroids in patients with radiologic midline shift, clinical deterioration after 48 hours, or elevated intracranial pressure. […] The diagnosis of acute infection often is difficult to make during pregnancy, and the administration of empiric antimicrobial therapy is discouraged. […] Spiramycin appears to be somewhat more easily tolerated than pyrimethamine-sulfonamide. […] A dosing regimen for pregnant patients is as follows: Spiramycin 1 g orally every 8 hours. […] Patients with AIDS are treated with pyrimethamine 200 mg orally initially, followed by 50-75 mg/day orally plus folinic acid 10 mg/day orally plus sulfadiazine 4-8 g/day orally for as long as 6 weeks, followed by lifelong suppressive therapy or until immune reconstitution.

• #20 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Most people with healthy immune systems recover from toxoplasmosis without treatment. […] Drugs are available for those who require treatment. […] Currently recommended treatment drugs for toxoplasmosis target the tachyzoite stage of the parasite and do not eradicate encysted parasites in the tissues. […] Pyrimethamine, considered the most effective drug against toxoplasmosis, is a standard component of therapy. […] A second drug, such as sulfadiazine or clindamycin (if the patient has a hypersensitivity reaction to sulfa drugs), should also be included. […] 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.

• #21 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Alternatives: Pyrimethamine + leucovorin + clindamycin 600 mg PO/IV four times daily. Add agent for PCP prophylaxis. TMP-SMX (TMP 5 mg/kg and SMX 25 mg/kg) IV/PO twice daily. Prosty et al. report evidence for TMP-SMX as the preferred therapy and describe similar efficacy with less toxicity and cost than pyrimethamine-containing regimens. […] If pt unable to take PO: Consider TMP/SMX IV OR clindamycin IV +/- oral pyrimethamine. Use the shortest duration possible if corticosteroids are needed for CNS mass effect. Anticonvulsants as prophylaxis are not recommended. […] Preferred: chronic maintenance Pyrimethamine 25-50 mg PO daily + sulfadiazine 2000-4000 mg PO in 2-4 divided doses + leucovorin 10-25 mg PO daily. Discontinue once asymptomatic and CD4 200 for 6 mos. […] Maternal treatment of primary toxoplasmosis or acute infection is the same as in non-pregnant adults. HIV: primary prophylaxis for TE with TMP/SMX also involves the potential for birth defect (cardiovascular) risk of TMP/SMX during the first trimester.

• #22 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  For many years, the initial therapy of choice for TE has been the combination of pyrimethamine plus sulfadiazine plus leucovorin. Pyrimethamine penetrates the brain parenchyma efficiently even in the absence of inflammation. Leucovorin reduces the likelihood of hematologic toxicities associated with pyrimethamine therapy. Pyrimethamine, however, has become extremely expensive and can be difficult to obtain in the United States. […] TMP-SMX has been used with increasing frequency as a preferred regimen, although large, randomized trials comparing TMP-SMX to pyrimethamine plus sulfadiazine have not been performed. In a small (77 patients) randomized trial, TMP-SMX was reported to be as effective and better tolerated than pyrimethamine-sulfadiazine. […] Clinical response to acute therapy occurs in ~90% of patients with TE within 14 days of initiating appropriate anti-Toxoplasma treatment. The reasons why some patients fail therapy are not clearly proven; whether such failures are due to poor adherence, other host factors, or antimicrobial resistance has not been well delineated. Acute therapy for TE should be continued for 6 weeks, if there is clinical and radiologic improvement. Longer courses may be necessary if clinical or radiologic disease is extensive or response is incomplete at 6 weeks. After completion of the acute therapy, all patients should be continued on chronic maintenance therapy as outlined below.

• #23 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  For many years, the initial therapy of choice for TE has been the combination of pyrimethamine plus sulfadiazine plus leucovorin. Pyrimethamine penetrates the brain parenchyma efficiently even in the absence of inflammation. Leucovorin reduces the likelihood of hematologic toxicities associated with pyrimethamine therapy. Pyrimethamine, however, has become extremely expensive and can be difficult to obtain in the United States. […] TMP-SMX has been used with increasing frequency as a preferred regimen, although large, randomized trials comparing TMP-SMX to pyrimethamine plus sulfadiazine have not been performed. In a small (77 patients) randomized trial, TMP-SMX was reported to be as effective and better tolerated than pyrimethamine-sulfadiazine. […] Clinical response to acute therapy occurs in ~90% of patients with TE within 14 days of initiating appropriate anti-Toxoplasma treatment. The reasons why some patients fail therapy are not clearly proven; whether such failures are due to poor adherence, other host factors, or antimicrobial resistance has not been well delineated. Acute therapy for TE should be continued for 6 weeks, if there is clinical and radiologic improvement. Longer courses may be necessary if clinical or radiologic disease is extensive or response is incomplete at 6 weeks. After completion of the acute therapy, all patients should be continued on chronic maintenance therapy as outlined below.

• #24 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  For many years, the initial therapy of choice for TE has been the combination of pyrimethamine plus sulfadiazine plus leucovorin. Pyrimethamine penetrates the brain parenchyma efficiently even in the absence of inflammation. Leucovorin reduces the likelihood of hematologic toxicities associated with pyrimethamine therapy. Pyrimethamine, however, has become extremely expensive and can be difficult to obtain in the United States. […] TMP-SMX has been used with increasing frequency as a preferred regimen, although large, randomized trials comparing TMP-SMX to pyrimethamine plus sulfadiazine have not been performed. In a small (77 patients) randomized trial, TMP-SMX was reported to be as effective and better tolerated than pyrimethamine-sulfadiazine. […] Clinical response to acute therapy occurs in ~90% of patients with TE within 14 days of initiating appropriate anti-Toxoplasma treatment. The reasons why some patients fail therapy are not clearly proven; whether such failures are due to poor adherence, other host factors, or antimicrobial resistance has not been well delineated. Acute therapy for TE should be continued for 6 weeks, if there is clinical and radiologic improvement. Longer courses may be necessary if clinical or radiologic disease is extensive or response is incomplete at 6 weeks. After completion of the acute therapy, all patients should be continued on chronic maintenance therapy as outlined below.

• #25 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Alternatives: Pyrimethamine + leucovorin + clindamycin 600 mg PO/IV four times daily. Add agent for PCP prophylaxis. TMP-SMX (TMP 5 mg/kg and SMX 25 mg/kg) IV/PO twice daily. Prosty et al. report evidence for TMP-SMX as the preferred therapy and describe similar efficacy with less toxicity and cost than pyrimethamine-containing regimens. […] If pt unable to take PO: Consider TMP/SMX IV OR clindamycin IV +/- oral pyrimethamine. Use the shortest duration possible if corticosteroids are needed for CNS mass effect. Anticonvulsants as prophylaxis are not recommended. […] Preferred: chronic maintenance Pyrimethamine 25-50 mg PO daily + sulfadiazine 2000-4000 mg PO in 2-4 divided doses + leucovorin 10-25 mg PO daily. Discontinue once asymptomatic and CD4 200 for 6 mos. […] Maternal treatment of primary toxoplasmosis or acute infection is the same as in non-pregnant adults. HIV: primary prophylaxis for TE with TMP/SMX also involves the potential for birth defect (cardiovascular) risk of TMP/SMX during the first trimester.

• #26 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  In general, induction therapy should be continued for at least 6 weeks. […] Since the currently available anti-T. gondii therapy cannot eradicate the protozoan, induction therapy should be followed by maintenance therapy as long as the patient remains significantly immunosuppressed. […] The risk of relapse is more than 50% in the absence of maintenance therapy. […] While pyr-sulf combination therapy is the current gold standard for the treatment of acute TE in HIV patients, pyrimethamine-clindamycin and TMP-SMX also seem to be similarly effective; however, no regimen has been found to be superior to pyr-sulf. […] The choice of therapy should be guided by drug availability, tolerability, and the ability of patients to take medications enterally. […] The clinical experience with other regimens (atovaquone monotherapy, atovaquone with pyrimethamine or sulfadiazine, and pyrimethamine with azithromycin or clarithromycin) is limited, and these should be used only in the absence of alternatives. […] Treatment should be started as soon as feasible after birth and continued for at least 1 year.

• #27 Toxoplasmosis: Symptoms, Pregnancy Risks, Diagnosis, Treatment

  https://www.webmd.com/baby/toxoplasmosis

  Toxoplasmosis Treatment […] If you are HIV-positive or have AIDS, your doctor may recommend the antibiotic sulfadiazine, along with a medication usually used to treat malaria called pyrimethamine (Daraprim). […] For a pregnant woman whose baby hasn’t been affected, the doctor might prescribe an antibiotic called spiramycin. It’s used to treat toxoplasmosis in Europe but is still being tested in the United States. […] If your baby is also infected or is likely to be, the doctor may recommend sulfadiazine and pyrimethamine, but only after the 16th week of pregnancy. Your doctor will watch the baby closely for signs of problems.

• #28 Toxoplasmosis: Causes, symptoms, and treatment

  https://www.medicalnewstoday.com/articles/308568

  Toxoplasmosis does not always require treatment, especially in healthy individuals. […] In certain situations, however, such as with pregnant women or those who are immunocompromised, medications may be recommended to decrease the severity of the toxoplasmosis infection. […] The doctor may recommend treatment with medications such as pyrimethamine (Daraprim) and sulfadiazine. However, symptoms will often clear up without the need for treatment. […] It may also be recommended that you take folic acid during treatment, as pyrimethamine may interrupt absorption of the mineral folate. Side effects of the medication include suppression of bone marrow activity and toxicity in the liver. […] The treatment for those living with HIV or AIDS involves taking pyrimethamine alongside either sulfadiazine or clindamycin (Cleocin). Clindamycin can, however, cause severe diarrhea. Therapy may be lifelong in certain situations.

• #29 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Most people with healthy immune systems recover from toxoplasmosis without treatment. […] Drugs are available for those who require treatment. […] Currently recommended treatment drugs for toxoplasmosis target the tachyzoite stage of the parasite and do not eradicate encysted parasites in the tissues. […] Pyrimethamine, considered the most effective drug against toxoplasmosis, is a standard component of therapy. […] A second drug, such as sulfadiazine or clindamycin (if the patient has a hypersensitivity reaction to sulfa drugs), should also be included. […] 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.

• #30 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Most people with healthy immune systems recover from toxoplasmosis without treatment. […] Drugs are available for those who require treatment. […] Currently recommended treatment drugs for toxoplasmosis target the tachyzoite stage of the parasite and do not eradicate encysted parasites in the tissues. […] Pyrimethamine, considered the most effective drug against toxoplasmosis, is a standard component of therapy. […] A second drug, such as sulfadiazine or clindamycin (if the patient has a hypersensitivity reaction to sulfa drugs), should also be included. […] 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.

• #31 Toxoplasmosis – Infectious Diseases – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/infectious-diseases/extraintestinal-protozoa/toxoplasmosis

  Treatment is most often with pyrimethamine plus either sulfadiazine or clindamycin. […] Treatment of toxoplasmosis is not indicated for immunocompetent patients who are asymptomatic or have mild, uncomplicated acute infection; treatment is required only when visceral disease is present or symptoms are severe or persist. […] However, specific treatment is indicated for acute toxoplasmosis in the following: neonates, pregnant women with acute toxoplasmosis, immunocompromised patients. […] The most effective regimen in immunocompetent patients with visceral involvement or severe or persistent symptoms is pyrimethamine plus sulfadiazine, for 2 to 4 weeks. […] In patients who have or develop sulfonamide hypersensitivity, clindamycin 600 to 800 mg orally 3 times a day is given with pyrimethamine and leucovorin instead of sulfonamides.

• #32 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  Toxoplasma gondii is a protozoan that can commonly cause asymptomatic infection, a mononucleosis-like syndrome, retinochoroiditis, or congenital infection in immunocompetent individuals, but it presents most often as toxoplasma encephalitis (TE) in people with HIV who are severely immunocompromised. Toxoplasmosis in people with HIV appears to occur mainly due to reactivation of latent tissue cysts from a prior infection; primary infection is occasionally associated with acute cerebral or disseminated disease. […] The preferred primary prophylaxis regimen is one double-strength tablet daily of TMP-SMX. This is also the preferred prophylaxis regimen for Pneumocystis jirovecii pneumonia (PCP), which all people at risk for toxoplasmosis are also at risk for developing. TMP-SMX, one double-strength tablet three times weekly, is an alternative. TMP-SMX, one single-strength tablet daily, is also an option. If TMP-SMX cannot be tolerated, the recommended alternative is dapsone plus pyrimethamine plus leucovorin, which also is effective against PCP.

• #33 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Acute, self-limited disease in an immunocompetent, non-pregnant individual usually requires no treatment. Treatment is recommended if an individual presents with visceral disease or the symptoms are severe or persistent. […] TE is often treated empirically; evidence of clinical and radiographic response to 2 weeks of therapy supports the diagnosis. Preferred: treatment duration, 6 weeks: Pyrimethamine 200 mg PO once, then weight-based: 60 kg: pyrimethamine 50 mg PO daily + sulfadiazine 1000 mg PO q6hr + leucovorin 10-25 mg PO daily. 60 kg: pyrimethamine 75 mg PO daily + sulfadiazine 1500 mg PO q6hr + leucovorin 10-25 mg PO daily. […] Duration: If the response to therapy is slow or incomplete, 6 weeks may be required for initial therapy. Leucovorin (folinic acid) 10-25 mg PO daily reverses bone marrow suppression of pyrimethamine.

• #34 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  The 6-week regimen is as follows: Pyrimethamine (100mg loading dose orally followed by 25-50 mg/day) plus sulfadiazine (2-4 g/day divided 4 times daily) OR Pyrimethamine (100-mg loading dose orally followed by 25-50 mg/day) plus clindamycin (300 mg orally 4 times daily). […] Consider steroids in patients with radiologic midline shift, clinical deterioration after 48 hours, or elevated intracranial pressure. […] The diagnosis of acute infection often is difficult to make during pregnancy, and the administration of empiric antimicrobial therapy is discouraged. […] Spiramycin appears to be somewhat more easily tolerated than pyrimethamine-sulfonamide. […] A dosing regimen for pregnant patients is as follows: Spiramycin 1 g orally every 8 hours. […] Patients with AIDS are treated with pyrimethamine 200 mg orally initially, followed by 50-75 mg/day orally plus folinic acid 10 mg/day orally plus sulfadiazine 4-8 g/day orally for as long as 6 weeks, followed by lifelong suppressive therapy or until immune reconstitution.

• #35 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  The 6-week regimen is as follows: Pyrimethamine (100mg loading dose orally followed by 25-50 mg/day) plus sulfadiazine (2-4 g/day divided 4 times daily) OR Pyrimethamine (100-mg loading dose orally followed by 25-50 mg/day) plus clindamycin (300 mg orally 4 times daily). […] Consider steroids in patients with radiologic midline shift, clinical deterioration after 48 hours, or elevated intracranial pressure. […] The diagnosis of acute infection often is difficult to make during pregnancy, and the administration of empiric antimicrobial therapy is discouraged. […] Spiramycin appears to be somewhat more easily tolerated than pyrimethamine-sulfonamide. […] A dosing regimen for pregnant patients is as follows: Spiramycin 1 g orally every 8 hours. […] Patients with AIDS are treated with pyrimethamine 200 mg orally initially, followed by 50-75 mg/day orally plus folinic acid 10 mg/day orally plus sulfadiazine 4-8 g/day orally for as long as 6 weeks, followed by lifelong suppressive therapy or until immune reconstitution.

• #36 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  In general, induction therapy should be continued for at least 6 weeks. […] Since the currently available anti-T. gondii therapy cannot eradicate the protozoan, induction therapy should be followed by maintenance therapy as long as the patient remains significantly immunosuppressed. […] The risk of relapse is more than 50% in the absence of maintenance therapy. […] While pyr-sulf combination therapy is the current gold standard for the treatment of acute TE in HIV patients, pyrimethamine-clindamycin and TMP-SMX also seem to be similarly effective; however, no regimen has been found to be superior to pyr-sulf. […] The choice of therapy should be guided by drug availability, tolerability, and the ability of patients to take medications enterally. […] The clinical experience with other regimens (atovaquone monotherapy, atovaquone with pyrimethamine or sulfadiazine, and pyrimethamine with azithromycin or clarithromycin) is limited, and these should be used only in the absence of alternatives. […] Treatment should be started as soon as feasible after birth and continued for at least 1 year.

• #37 How to Identify and Treat Toxoplasmosis Infection

  https://www.healthline.com/health/toxoplasmosis

  In people with HIV, treatment continues until levels of CD4 cells, the immune cell impacted by HIV, improve and viral load is suppressed by antiretroviral therapy. This is because its possible for toxoplasmosis to reactivate when CD4 counts are low. […] Treatment during pregnancy is somewhat different. Your course of treatment will depend on the severity of the infection and whether the fetus has contracted it. […] Newborns with signs or symptoms of toxoplasmosis are typically treated with a combination of pyrimethamine, sulfadiazine, and folinic acid for 12 months. […] However, both pyrimethamine and sulfadiazine can have significant side effects like liver toxicity and suppression of the bone marrow that helps produce blood cells. Because of this, these infants will need to have regular monitoring of their blood counts and liver function.

• #38 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  Patients with AIDS, CNS toxoplasmosis, and evidence of midline shift or increased intracranial pressure may also benefit from steroid therapy. […] The mere presence of a focus of retinitis is not always an indication for treatment. […] In addition, experts differ on their preferred initial treatment. In a report, one third of respondents preferred triple therapy (ie, pyrimethamine, sulfadiazine, prednisone), and a little more than one quarter of respondents preferred quadruple therapy (ie, pyrimethamine, sulfadiazine, clindamycin, prednisone). […] Trimethoprim-sulfamethoxazole seems to be as effective as pyrimethamine and sulfadiazine, but with a significantly improved safety profile, whereas intermittent trimethoprim-sulfamethoxazole prophylaxis over 12 months is capable of preventing recurrences of the ocular toxoplasmosis.

• #39 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  Adjunctive corticosteroids such as dexamethasone should only be used for treatment of patients with TE when they are clinically indicated to treat a mass effect associated with focal lesions or associated edema. In those treated with corticosteroids, caution may be needed in diagnosing CNS toxoplasmosis on the basis of treatment response, since primary CNS lymphoma may respond clinically and radiographically to corticosteroids alone; these patients should be monitored carefully as corticosteroids are tapered.

• #40 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Treatment for ocular diseases should be based on a complete ophthalmologic evaluation. […] Management of ocular toxoplasmosis may vary depending on the treatment center, but usually consists of an anti-parasitic drug with corticosteroids as needed to control inflammation. […] Therapy should be given for 4 to 6 weeks, followed by reevaluation of the patients condition. […] Treatment is recommended for at least 4 to 6 weeks beyond resolution of all clinical signs and symptoms but may be required for 6 months or longer. […] Pyrimethamine, folinic acid (leucovorin), and sulfadiazine are standards of therapy for immunodeficient patients. […] Congenitally infected newborns are generally treated with pyrimethamine, a sulfonamide, and leucovorin for 12 months. […] Recommendations from the National Reference Laboratory for Toxoplasmosis (PAMF-TSL) and the Toxoplasmosis Center at the University of Chicago for treatment of congenitally infected infants are:

• #41 Toxoplasmosis – EyeWiki

  https://eyewiki.org/Toxoplasmosis

  Toxoplasma Serotypes: […] Type 1: Latin America more severe disease […] Type 2: Europe/North America less aggressive […] […] […] Not all lesions warrant treatment. Indications for treatment include: […] Macular threatening or optic nerve or papillomacular lesions […] Close proximity of lesions to major retinal vessels […] Dense vitritis […] Marked visual impairment […] Larger lesions […] Pregnancy […] Monocular status […] The immunocompromised host […] […] […] Systemic Pyrimethamine, sulfadiazine, and corticosteroids […] This is the classic triple therapy used in the treatment of toxoplasmosis. In a survey of the American Uveitis Society this combination triple therapy was cited as the treatment of choice by 32% of respondents. Of note, Pyrimethamine is a folic acid antagonist and can cause dose-related suppression of the bone marrow, which is mitigated by concurrent administration of folinic acid (leucovorin)

• #42 Toxoplasmosis – EyeWiki

  https://eyewiki.org/Toxoplasmosis

  Toxoplasma Serotypes: […] Type 1: Latin America more severe disease […] Type 2: Europe/North America less aggressive […] […] […] Not all lesions warrant treatment. Indications for treatment include: […] Macular threatening or optic nerve or papillomacular lesions […] Close proximity of lesions to major retinal vessels […] Dense vitritis […] Marked visual impairment […] Larger lesions […] Pregnancy […] Monocular status […] The immunocompromised host […] […] […] Systemic Pyrimethamine, sulfadiazine, and corticosteroids […] This is the classic triple therapy used in the treatment of toxoplasmosis. In a survey of the American Uveitis Society this combination triple therapy was cited as the treatment of choice by 32% of respondents. Of note, Pyrimethamine is a folic acid antagonist and can cause dose-related suppression of the bone marrow, which is mitigated by concurrent administration of folinic acid (leucovorin)

• #43 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Treatment for ocular diseases should be based on a complete ophthalmologic evaluation. […] Management of ocular toxoplasmosis may vary depending on the treatment center, but usually consists of an anti-parasitic drug with corticosteroids as needed to control inflammation. […] Therapy should be given for 4 to 6 weeks, followed by reevaluation of the patients condition. […] Treatment is recommended for at least 4 to 6 weeks beyond resolution of all clinical signs and symptoms but may be required for 6 months or longer. […] Pyrimethamine, folinic acid (leucovorin), and sulfadiazine are standards of therapy for immunodeficient patients. […] Congenitally infected newborns are generally treated with pyrimethamine, a sulfonamide, and leucovorin for 12 months. […] Recommendations from the National Reference Laboratory for Toxoplasmosis (PAMF-TSL) and the Toxoplasmosis Center at the University of Chicago for treatment of congenitally infected infants are:

• #44 Ocular Toxoplasmosis: Advances in Toxoplasma gondii Biology, Clinical Manifestations, Diagnostics, and Therapy

  https://www.mdpi.com/2076-0817/13/10/898

  In cases of excessive immune response leading to additional tissue damage or disease exacerbation, corticosteroids or other immunosuppressants may be necessary to modulate immune response intensity and prevent further ocular tissue damage. The classic “triple therapy” includes pyrimethamine, sulfadiazine, and systemic corticosteroids (most commonly prednisone). Notably, in the absence of concurrent antiparasitic medication, the administration of corticosteroids is significantly more likely to result in adverse outcomes. […] Trimethoprim-sulfamethoxazole (TMP-SMX) is another important antibiotic combination used in the treatment of OT. The rationale behind the use of TMP-SMX is that trimethoprim inhibits the synthesis of tetrahydrofolate, while sulfamethoxazole blocks the utilization of para-aminobenzoic acid, another essential component for the parasite’s growth. One of the advantages of TMP-SMX is its relatively good ocular penetration and bioavailability, which allows the drugs to reach therapeutic concentrations in the eye. Additionally, TMP-SMX is generally well-tolerated, with the most common side effects being gastrointestinal disturbances and skin rashes. Accumulating evidence demonstrates that TMP-SMX, either as monotherapy or in combination with corticosteroids, effectively mitigates the inflammatory response, enhances visual outcomes, and reduces recurrence rates in patients with OT. Furthermore, studies have shown that the use of TMP-SMX as a maintenance or suppressive therapy can significantly reduce the risk of recurrence in patients with a history of frequent and/or severe relapses of Toxoplasma retinochoroiditis. This adjunctive prophylactic treatment with TMP-SMX may be particularly beneficial for select individuals who have demonstrated a propensity for recurrent OT episodes. However, it is important to note that some patients may develop hypersensitivity reactions or experience more severe adverse effects, such as Stevens-Johnson syndrome or toxic epidermal necrolysis, with TMP-SMX therapy. In such cases, alternative antibiotic combinations or regimens may need to be considered.

• #45 How to Diagnose & Treat Ocular Toxoplasmosis

  https://www.reviewofophthalmology.com/article/how-to-diagnose-treat-ocular-toxoplasmosis

  The most common treatment for ocular toxoplasmosis is so-called classic therapy, which consists of pyrimethamine and sulfadiazine plus corticosteroids. […] Alternative treatment regimens include quadruple drug therapy (classic regimen plus clindamycin), as well as single or combined use of clindamycin, trimethoprim/sulfamethoxazole, spiramycine, minocycline, azithromycin, atovaquone and clarithromycin. […] One recently popularized alternative treatment involves use of trimethoprim (80 mg)/sulfamethoxazole (400 mg) every 12 hours plus oral prednisone (1 mg/kg started after three days). […] Treatment of toxoplasmosis retinochoroiditis with intravitreal injection of clindamycin and dexamethasone has had promising effects. […] Newborns and infants with congenital ocular toxoplasmosis should receive treatment within the first year of life with a combination of pyrimethamine, sulfadiazine and folinic acid.

• #46 How to Diagnose & Treat Ocular Toxoplasmosis

  https://www.reviewofophthalmology.com/article/how-to-diagnose-treat-ocular-toxoplasmosis

  The most common treatment for ocular toxoplasmosis is so-called classic therapy, which consists of pyrimethamine and sulfadiazine plus corticosteroids. […] Alternative treatment regimens include quadruple drug therapy (classic regimen plus clindamycin), as well as single or combined use of clindamycin, trimethoprim/sulfamethoxazole, spiramycine, minocycline, azithromycin, atovaquone and clarithromycin. […] One recently popularized alternative treatment involves use of trimethoprim (80 mg)/sulfamethoxazole (400 mg) every 12 hours plus oral prednisone (1 mg/kg started after three days). […] Treatment of toxoplasmosis retinochoroiditis with intravitreal injection of clindamycin and dexamethasone has had promising effects. […] Newborns and infants with congenital ocular toxoplasmosis should receive treatment within the first year of life with a combination of pyrimethamine, sulfadiazine and folinic acid.

• #47 Ocular Toxoplasmosis: Advances in Toxoplasma gondii Biology, Clinical Manifestations, Diagnostics, and Therapy

  https://www.mdpi.com/2076-0817/13/10/898

  In cases of excessive immune response leading to additional tissue damage or disease exacerbation, corticosteroids or other immunosuppressants may be necessary to modulate immune response intensity and prevent further ocular tissue damage. The classic “triple therapy” includes pyrimethamine, sulfadiazine, and systemic corticosteroids (most commonly prednisone). Notably, in the absence of concurrent antiparasitic medication, the administration of corticosteroids is significantly more likely to result in adverse outcomes. […] Trimethoprim-sulfamethoxazole (TMP-SMX) is another important antibiotic combination used in the treatment of OT. The rationale behind the use of TMP-SMX is that trimethoprim inhibits the synthesis of tetrahydrofolate, while sulfamethoxazole blocks the utilization of para-aminobenzoic acid, another essential component for the parasite’s growth. One of the advantages of TMP-SMX is its relatively good ocular penetration and bioavailability, which allows the drugs to reach therapeutic concentrations in the eye. Additionally, TMP-SMX is generally well-tolerated, with the most common side effects being gastrointestinal disturbances and skin rashes. Accumulating evidence demonstrates that TMP-SMX, either as monotherapy or in combination with corticosteroids, effectively mitigates the inflammatory response, enhances visual outcomes, and reduces recurrence rates in patients with OT. Furthermore, studies have shown that the use of TMP-SMX as a maintenance or suppressive therapy can significantly reduce the risk of recurrence in patients with a history of frequent and/or severe relapses of Toxoplasma retinochoroiditis. This adjunctive prophylactic treatment with TMP-SMX may be particularly beneficial for select individuals who have demonstrated a propensity for recurrent OT episodes. However, it is important to note that some patients may develop hypersensitivity reactions or experience more severe adverse effects, such as Stevens-Johnson syndrome or toxic epidermal necrolysis, with TMP-SMX therapy. In such cases, alternative antibiotic combinations or regimens may need to be considered.

• #48 Treatment of ocular toxoplasmosis – Australian Prescriber

  https://australianprescriber.tg.org.au/articles/treatment-of-ocular-toxoplasmosis.html

  Ocular toxoplasmosis is a potentially blinding cause of posterior uveitis. […] Current treatments do not effect a cure nor do they prevent recurrences. Their role lies in minimising the damaging effects of inflammation and limiting lesion size, particularly when sight is threatened. […] The need for therapy, type of drug treatment and duration of therapy needs to be individualised. […] Therapy is usually needed for 6 to 12 weeks in immunocompetent patients and a response is determined clinically when the retinal lesions lose their fluffy white appearance, the vitreous clears and an atrophic chorioretinal scar with sharp margins develops. […] Immunocompromised patients such as transplant recipients and patients with HIV infection may require long-term suppressive therapy. Pyrimethamine and/or sulfadiazine can be used to maintain control of infection.

• #49 Gestational toxoplasmosis treatment changes the child’s prognosis: A cohort study in southern Brazil | PLOS Neglected Tropical Diseases

  https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0011544

  We evaluate the drug treatment for pregnant women with acute toxoplasmosis to reduce the risk of congenital infection, side effects (prenatal and postnatal treatment in children) and the hazard of discontinuing the infants medication. […] Prenatal treatment for Toxoplasma infection aims to prevent neurological or visual impairment by the reduction of mother-to-child transmission of infection or, once the fetal infection has occurred, by limiting cell damage caused by the parasite. […] In this study, we evaluated the benefit of drug treatment for pregnant women with acute toxoplasmosis as a protective factor in reducing the risk of congenital infection. Also, we evaluated the side effects of prenatal and postnatal drug treatment in children and assessed the risk of discontinuing the drug treatment in infants after two decreasing IgG anti-T. gondii serology tests.

• #50 Toxoplasmosis – Wikipedia

  https://en.wikipedia.org/wiki/Toxoplasmosis

  Treatment During pregnancy spiramycin or pyrimethamine/sulfadiazine and folinic acid may be used for treatment. […] The medications prescribed for acute toxoplasmosis are the following: Pyrimethamine an antimalarial medication, Sulfadiazine an antibiotic used in combination with pyrimethamine to treat toxoplasmosis, Clindamycin, Spiramycin an antibiotic used most often for pregnant women to prevent the infection of their children. […] If infected during pregnancy, spiramycin is recommended in the first and early second trimesters while pyrimethamine/sulfadiazine and leucovorin is recommended in the late second and third trimesters. […] In people with latent toxoplasmosis, the cysts are immune to these treatments, as the antibiotics do not reach the bradyzoites in sufficient concentration.

• #51 Toxoplasmosis Medication: Sulfonamide, Antibiotics, Other, Lincosamide Antimicrobials, Antiprotozoal Agents, Macrolides, Corticosteroids, Antidotes, Cycloplegics/Mydriatics

  https://emedicine.medscape.com/article/229969-medication

  The 6-week regimen is as follows: Pyrimethamine (100mg loading dose orally followed by 25-50 mg/day) plus sulfadiazine (2-4 g/day divided 4 times daily) OR Pyrimethamine (100-mg loading dose orally followed by 25-50 mg/day) plus clindamycin (300 mg orally 4 times daily). […] Consider steroids in patients with radiologic midline shift, clinical deterioration after 48 hours, or elevated intracranial pressure. […] The diagnosis of acute infection often is difficult to make during pregnancy, and the administration of empiric antimicrobial therapy is discouraged. […] Spiramycin appears to be somewhat more easily tolerated than pyrimethamine-sulfonamide. […] A dosing regimen for pregnant patients is as follows: Spiramycin 1 g orally every 8 hours. […] Patients with AIDS are treated with pyrimethamine 200 mg orally initially, followed by 50-75 mg/day orally plus folinic acid 10 mg/day orally plus sulfadiazine 4-8 g/day orally for as long as 6 weeks, followed by lifelong suppressive therapy or until immune reconstitution.

• #52 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Prevention of vertical transmission: Early pregnancy/first trimester, if the mother is found to seroconvert Spiramycin 1g every 8 hr does not cross the placenta and is not used for fetal treatment. Beyond 1st trimester (18wks) or confirmed fetal infection (e.g., by PCR): Pyrimethamine 50 mg twice daily x 2d then 50 mg per day + sulfadiazine 75 mg/kg/d in two divided doses x 2d then 50 mg/kg twice daily + leucovorin 10-20 mg daily. It may reduce the risk of congenital toxoplasmosis development or treat fetal infection. Due to teratogenicity concerns, pyrimethamine should not be used in the first trimester. […] Oral systemic classic therapy: use sulfadiazine, pyrimethamine, leucovorin and systemic corticosteroids. Limited by adverse drug reactions (reversible pancytopenia, GI intolerance, neurologic effects). No role for steroids as a sole therapy; antiparasitic agents must accompany them. TMP-SMX is increasingly preferred due to greater availability and lower cost than pyrimethamine.

• #53 Toxoplasmosis: Causes, symptoms, and treatment

  https://www.medicalnewstoday.com/articles/308568

  The antibiotic spiramycin may be recommended if you are pregnant and have toxoplasmosis without passing it on to the fetus. However, this treatment is currently experimental in the U.S. […] If a woman transmits toxoplasmosis to the fetus during pregnancy, doctors typically recommend treatment with pyrimethamine and sulfadiazine. This does not completely eliminate the T. gondii cells but forces them to remain dormant in certain tissues. […] Once born, infants can be treated with a regimen including pyrimethamine, sulfadiazine, and folic acid.

• #54 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Prevention of vertical transmission: Early pregnancy/first trimester, if the mother is found to seroconvert Spiramycin 1g every 8 hr does not cross the placenta and is not used for fetal treatment. Beyond 1st trimester (18wks) or confirmed fetal infection (e.g., by PCR): Pyrimethamine 50 mg twice daily x 2d then 50 mg per day + sulfadiazine 75 mg/kg/d in two divided doses x 2d then 50 mg/kg twice daily + leucovorin 10-20 mg daily. It may reduce the risk of congenital toxoplasmosis development or treat fetal infection. Due to teratogenicity concerns, pyrimethamine should not be used in the first trimester. […] Oral systemic classic therapy: use sulfadiazine, pyrimethamine, leucovorin and systemic corticosteroids. Limited by adverse drug reactions (reversible pancytopenia, GI intolerance, neurologic effects). No role for steroids as a sole therapy; antiparasitic agents must accompany them. TMP-SMX is increasingly preferred due to greater availability and lower cost than pyrimethamine.

• #55 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Prevention of vertical transmission: Early pregnancy/first trimester, if the mother is found to seroconvert Spiramycin 1g every 8 hr does not cross the placenta and is not used for fetal treatment. Beyond 1st trimester (18wks) or confirmed fetal infection (e.g., by PCR): Pyrimethamine 50 mg twice daily x 2d then 50 mg per day + sulfadiazine 75 mg/kg/d in two divided doses x 2d then 50 mg/kg twice daily + leucovorin 10-20 mg daily. It may reduce the risk of congenital toxoplasmosis development or treat fetal infection. Due to teratogenicity concerns, pyrimethamine should not be used in the first trimester. […] Oral systemic classic therapy: use sulfadiazine, pyrimethamine, leucovorin and systemic corticosteroids. Limited by adverse drug reactions (reversible pancytopenia, GI intolerance, neurologic effects). No role for steroids as a sole therapy; antiparasitic agents must accompany them. TMP-SMX is increasingly preferred due to greater availability and lower cost than pyrimethamine.

• #56 Full year of treatment helps infants and children with toxoplasmosis – UChicago Medicine

  https://www.uchicagomedicine.org/forefront/news/2006/may/full-year-of-treatment-helps-infants-and-children-with-toxoplasmosis

  Full year of treatment helps infants and children with toxoplasmosis. The first long-term study shows that treatment with pyrimethamine and sulfadiazine (two anti-parasitic drugs) during the first year of life leads to a lasting reduction in brain and eye damage for children with congenital toxoplasmosis. […] Patients were treated with pyrimethamine at one of two different dose levels and sulfadiazine for one year and then followed periodically. […] This congenital infection, they added, is „preventable and treatable.” […] This promising result provides „compelling evidence” for prolonged treatment, she said. Because such treatment improves outcome, „it may be time to consider a more comprehensive plan for neonatal screening for congenital toxoplasmosis.”

• #57 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  In general, induction therapy should be continued for at least 6 weeks. […] Since the currently available anti-T. gondii therapy cannot eradicate the protozoan, induction therapy should be followed by maintenance therapy as long as the patient remains significantly immunosuppressed. […] The risk of relapse is more than 50% in the absence of maintenance therapy. […] While pyr-sulf combination therapy is the current gold standard for the treatment of acute TE in HIV patients, pyrimethamine-clindamycin and TMP-SMX also seem to be similarly effective; however, no regimen has been found to be superior to pyr-sulf. […] The choice of therapy should be guided by drug availability, tolerability, and the ability of patients to take medications enterally. […] The clinical experience with other regimens (atovaquone monotherapy, atovaquone with pyrimethamine or sulfadiazine, and pyrimethamine with azithromycin or clarithromycin) is limited, and these should be used only in the absence of alternatives. […] Treatment should be started as soon as feasible after birth and continued for at least 1 year.

• #58 Full year of treatment helps infants and children with toxoplasmosis – UChicago Medicine

  https://www.uchicagomedicine.org/forefront/news/2006/may/full-year-of-treatment-helps-infants-and-children-with-toxoplasmosis

  Full year of treatment helps infants and children with toxoplasmosis. The first long-term study shows that treatment with pyrimethamine and sulfadiazine (two anti-parasitic drugs) during the first year of life leads to a lasting reduction in brain and eye damage for children with congenital toxoplasmosis. […] Patients were treated with pyrimethamine at one of two different dose levels and sulfadiazine for one year and then followed periodically. […] This congenital infection, they added, is „preventable and treatable.” […] This promising result provides „compelling evidence” for prolonged treatment, she said. Because such treatment improves outcome, „it may be time to consider a more comprehensive plan for neonatal screening for congenital toxoplasmosis.”

• #59 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  Toxoplasma gondii is a protozoan that can commonly cause asymptomatic infection, a mononucleosis-like syndrome, retinochoroiditis, or congenital infection in immunocompetent individuals, but it presents most often as toxoplasma encephalitis (TE) in people with HIV who are severely immunocompromised. Toxoplasmosis in people with HIV appears to occur mainly due to reactivation of latent tissue cysts from a prior infection; primary infection is occasionally associated with acute cerebral or disseminated disease. […] The preferred primary prophylaxis regimen is one double-strength tablet daily of TMP-SMX. This is also the preferred prophylaxis regimen for Pneumocystis jirovecii pneumonia (PCP), which all people at risk for toxoplasmosis are also at risk for developing. TMP-SMX, one double-strength tablet three times weekly, is an alternative. TMP-SMX, one single-strength tablet daily, is also an option. If TMP-SMX cannot be tolerated, the recommended alternative is dapsone plus pyrimethamine plus leucovorin, which also is effective against PCP.

• #60 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  Toxoplasma gondii is a protozoan that can commonly cause asymptomatic infection, a mononucleosis-like syndrome, retinochoroiditis, or congenital infection in immunocompetent individuals, but it presents most often as toxoplasma encephalitis (TE) in people with HIV who are severely immunocompromised. Toxoplasmosis in people with HIV appears to occur mainly due to reactivation of latent tissue cysts from a prior infection; primary infection is occasionally associated with acute cerebral or disseminated disease. […] The preferred primary prophylaxis regimen is one double-strength tablet daily of TMP-SMX. This is also the preferred prophylaxis regimen for Pneumocystis jirovecii pneumonia (PCP), which all people at risk for toxoplasmosis are also at risk for developing. TMP-SMX, one double-strength tablet three times weekly, is an alternative. TMP-SMX, one single-strength tablet daily, is also an option. If TMP-SMX cannot be tolerated, the recommended alternative is dapsone plus pyrimethamine plus leucovorin, which also is effective against PCP.

• #61 Toxoplasma gondii Encephalitis: Adult and Adolescent OIs | NIH

  https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/toxoplasmosis

  Toxoplasma gondii is a protozoan that can commonly cause asymptomatic infection, a mononucleosis-like syndrome, retinochoroiditis, or congenital infection in immunocompetent individuals, but it presents most often as toxoplasma encephalitis (TE) in people with HIV who are severely immunocompromised. Toxoplasmosis in people with HIV appears to occur mainly due to reactivation of latent tissue cysts from a prior infection; primary infection is occasionally associated with acute cerebral or disseminated disease. […] The preferred primary prophylaxis regimen is one double-strength tablet daily of TMP-SMX. This is also the preferred prophylaxis regimen for Pneumocystis jirovecii pneumonia (PCP), which all people at risk for toxoplasmosis are also at risk for developing. TMP-SMX, one double-strength tablet three times weekly, is an alternative. TMP-SMX, one single-strength tablet daily, is also an option. If TMP-SMX cannot be tolerated, the recommended alternative is dapsone plus pyrimethamine plus leucovorin, which also is effective against PCP.

• #62 Toxoplasmosis Treatment & Management: Approach Considerations, Emergency Department Care, Deterrence and Prevention

  https://emedicine.medscape.com/article/229969-treatment

  Treatment usually is unnecessary in asymptomatic hosts, except in children younger than 5 years. Symptomatic patients should be treated until immunity is ensured. […] Outpatient care is sufficient for acquired toxoplasmosis in immunocompetent hosts and for persons with ocular toxoplasmosis. Inpatient care is appropriate initially for persons with CNS toxoplasmosis and for acute toxoplasmosis in immunocompromised hosts. […] Patients with AIDS who have a CD4 count of less than 100 cells/L should be commenced on suppressive therapy for T gondii until they undergo immune reconstitution. […] Follow-up visits should be scheduled every 2 weeks until the patient is stable, and then monthly during therapy. A CBC should be performed weekly for the first month, and then every 2 weeks. Renal and liver function tests should be performed monthly.

• #63 Toxoplasmosis Treatment & Management: Approach Considerations, Emergency Department Care, Deterrence and Prevention

  https://emedicine.medscape.com/article/229969-treatment

  Treatment usually is unnecessary in asymptomatic hosts, except in children younger than 5 years. Symptomatic patients should be treated until immunity is ensured. […] Outpatient care is sufficient for acquired toxoplasmosis in immunocompetent hosts and for persons with ocular toxoplasmosis. Inpatient care is appropriate initially for persons with CNS toxoplasmosis and for acute toxoplasmosis in immunocompromised hosts. […] Patients with AIDS who have a CD4 count of less than 100 cells/L should be commenced on suppressive therapy for T gondii until they undergo immune reconstitution. […] Follow-up visits should be scheduled every 2 weeks until the patient is stable, and then monthly during therapy. A CBC should be performed weekly for the first month, and then every 2 weeks. Renal and liver function tests should be performed monthly.

• #64 Toxoplasmosis Treatment & Management: Approach Considerations, Emergency Department Care, Deterrence and Prevention

  https://emedicine.medscape.com/article/229969-treatment

  Treatment usually is unnecessary in asymptomatic hosts, except in children younger than 5 years. Symptomatic patients should be treated until immunity is ensured. […] Outpatient care is sufficient for acquired toxoplasmosis in immunocompetent hosts and for persons with ocular toxoplasmosis. Inpatient care is appropriate initially for persons with CNS toxoplasmosis and for acute toxoplasmosis in immunocompromised hosts. […] Patients with AIDS who have a CD4 count of less than 100 cells/L should be commenced on suppressive therapy for T gondii until they undergo immune reconstitution. […] Follow-up visits should be scheduled every 2 weeks until the patient is stable, and then monthly during therapy. A CBC should be performed weekly for the first month, and then every 2 weeks. Renal and liver function tests should be performed monthly.

• #65

  https://step2.medbullets.com/neurology/120288/toxoplasmosis-cns

  Treatment […] Medical […] pyrimethamine + sulfadiazine + leucovorin […] can replace sulfadiazine with clindamycin in those intolerant to sulfa-drugs […] […] corticosteroids […] only in those with mass effect […] […] anticonvulsants […] only in those presenting with seizures […] […] Special considerations […] HIV […] CD4+ Count 100 mm3 […] for patients with a past medical history of HIV with severe immunosuppression (CD4 100 cells/L), focal neurologic findings, and ring-enhancing lesions on head imaging, the next step in management is empiric treatment for toxoplasma encephalitis with pyrimethamine-sulfadiazine for 10-14 days. […] get follow-up head imaging after 10-14 days. If the patient fails to improve clinically or the size of the lesion does not change, the next step would be a biopsy of the lesion.

• #66 Drugs in development for toxoplasmosis: advances, challenges, and curr | DDDT

  https://www.dovepress.com/drugs-in-development-for-toxoplasmosis-advances-challenges-and-current-peer-reviewed-fulltext-article-DDDT

  First-line therapy consists of the combination of pyrimethamine and sulfadiazine with leucovorin added to prevent hematologic toxicity. […] A review of 115 patients with Toxoplasma encephalitis found toxicity in 62% of patients and severe side effects requiring a change in therapy in 44% of patients. […] The need for nontoxic medicines is further emphasized by the prolonged courses of therapy required for treatment and suppression of infection. […] A promising aspect of several experimental compounds is activity against T. gondii tissue cysts that are established in mice 5 weeks prior to treatment. […] Drugs that are less toxic would greatly improve the care of patients with toxoplasmosis.

• #67 Toxoplasmosis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/toxoplasmosis/diagnosis-treatment/drc-20356255

  Medication is used to treat active infections. How much and how long you take medicine depends on different factors. These include how seriously ill you are, your immune system health and where the infection is located. Your stage of pregnancy is also a factor. […] Your provider may give you a combination of prescription drugs. They include: […] Pyrimethamine (Daraprim). This fights infections caused by microscopic organisms. It can block the body’s use of folic acid. Other possible side effects with long-term use include bone marrow suppression and liver toxicity. […] Sulfadiazine is an antibiotic often prescribed with pyrimethamine. Other medication includes clindamycin (Cleocin), azithromycin (Zithromax) and others. […] Drug treatment for infants may last 1 to 2 years. Regular and frequent follow-up appointments are needed to watch for side effects, vision problems, and physical, intellectual and overall development. […] In addition to the regular drug treatment, eye disease also may be treated with anti-inflammatory steroids called glucocorticosteroids.

• #68 Toxoplasmosis: Causes, symptoms, and treatment

  https://www.medicalnewstoday.com/articles/308568

  Toxoplasmosis does not always require treatment, especially in healthy individuals. […] In certain situations, however, such as with pregnant women or those who are immunocompromised, medications may be recommended to decrease the severity of the toxoplasmosis infection. […] The doctor may recommend treatment with medications such as pyrimethamine (Daraprim) and sulfadiazine. However, symptoms will often clear up without the need for treatment. […] It may also be recommended that you take folic acid during treatment, as pyrimethamine may interrupt absorption of the mineral folate. Side effects of the medication include suppression of bone marrow activity and toxicity in the liver. […] The treatment for those living with HIV or AIDS involves taking pyrimethamine alongside either sulfadiazine or clindamycin (Cleocin). Clindamycin can, however, cause severe diarrhea. Therapy may be lifelong in certain situations.

• #69 Toxoplasmosis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/toxoplasmosis/diagnosis-treatment/drc-20356255

  Medication is used to treat active infections. How much and how long you take medicine depends on different factors. These include how seriously ill you are, your immune system health and where the infection is located. Your stage of pregnancy is also a factor. […] Your provider may give you a combination of prescription drugs. They include: […] Pyrimethamine (Daraprim). This fights infections caused by microscopic organisms. It can block the body’s use of folic acid. Other possible side effects with long-term use include bone marrow suppression and liver toxicity. […] Sulfadiazine is an antibiotic often prescribed with pyrimethamine. Other medication includes clindamycin (Cleocin), azithromycin (Zithromax) and others. […] Drug treatment for infants may last 1 to 2 years. Regular and frequent follow-up appointments are needed to watch for side effects, vision problems, and physical, intellectual and overall development. […] In addition to the regular drug treatment, eye disease also may be treated with anti-inflammatory steroids called glucocorticosteroids.

• #70 Toxoplasmosis: Causes, symptoms, and treatment

  https://www.medicalnewstoday.com/articles/308568

  Toxoplasmosis does not always require treatment, especially in healthy individuals. […] In certain situations, however, such as with pregnant women or those who are immunocompromised, medications may be recommended to decrease the severity of the toxoplasmosis infection. […] The doctor may recommend treatment with medications such as pyrimethamine (Daraprim) and sulfadiazine. However, symptoms will often clear up without the need for treatment. […] It may also be recommended that you take folic acid during treatment, as pyrimethamine may interrupt absorption of the mineral folate. Side effects of the medication include suppression of bone marrow activity and toxicity in the liver. […] The treatment for those living with HIV or AIDS involves taking pyrimethamine alongside either sulfadiazine or clindamycin (Cleocin). Clindamycin can, however, cause severe diarrhea. Therapy may be lifelong in certain situations.

• #71 Toxoplasma gondii | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540558/all/Toxoplasma_gondii

  Acute, self-limited disease in an immunocompetent, non-pregnant individual usually requires no treatment. Treatment is recommended if an individual presents with visceral disease or the symptoms are severe or persistent. […] TE is often treated empirically; evidence of clinical and radiographic response to 2 weeks of therapy supports the diagnosis. Preferred: treatment duration, 6 weeks: Pyrimethamine 200 mg PO once, then weight-based: 60 kg: pyrimethamine 50 mg PO daily + sulfadiazine 1000 mg PO q6hr + leucovorin 10-25 mg PO daily. 60 kg: pyrimethamine 75 mg PO daily + sulfadiazine 1500 mg PO q6hr + leucovorin 10-25 mg PO daily. […] Duration: If the response to therapy is slow or incomplete, 6 weeks may be required for initial therapy. Leucovorin (folinic acid) 10-25 mg PO daily reverses bone marrow suppression of pyrimethamine.

• #72 Ocular Toxoplasmosis: Advances in Toxoplasma gondii Biology, Clinical Manifestations, Diagnostics, and Therapy

  https://www.mdpi.com/2076-0817/13/10/898

  Toxoplasma-associated chorioretinitis in immunocompetent patients is typically self-limiting, resolving within 4–8 weeks. The treatment of OT remains controversial due to the disease’s natural course and potential drug side effects. While some clinicians opt not to treat small peripheral retinal lesions, others treat all patients to reduce recurrence and complication rates. Treatment decisions for OT require consideration of infection severity, patient immune status, and potential complications. […] Antiparasitic drugs form the cornerstone of treatment, with pyrimethamine and sulfadiazine being commonly used. This combination inhibits parasite folate synthesis, thereby preventing nucleic acid synthesis and replication, ultimately suppressing T. gondii proliferation and reducing intraocular inflammation. While pyrimethamine and sulfadiazine remain the cornerstone therapies for OT, it is essential to conduct vigilant monitoring due to the possibility of adverse events. These include hematological abnormalities (leukopenia, thrombocytopenia), gastrointestinal disturbances, and dermatological reactions. To mitigate these risks, weekly complete blood count monitoring is imperative throughout the treatment course. Furthermore, concomitant folinic acid supplementation is essential to counteract the antifolate effects of pyrimethamine, thereby reducing the risk of bone marrow suppression.

• #73 Ocular Toxoplasmosis: Advances in Toxoplasma gondii Biology, Clinical Manifestations, Diagnostics, and Therapy

  https://www.mdpi.com/2076-0817/13/10/898

  Toxoplasma-associated chorioretinitis in immunocompetent patients is typically self-limiting, resolving within 4–8 weeks. The treatment of OT remains controversial due to the disease’s natural course and potential drug side effects. While some clinicians opt not to treat small peripheral retinal lesions, others treat all patients to reduce recurrence and complication rates. Treatment decisions for OT require consideration of infection severity, patient immune status, and potential complications. […] Antiparasitic drugs form the cornerstone of treatment, with pyrimethamine and sulfadiazine being commonly used. This combination inhibits parasite folate synthesis, thereby preventing nucleic acid synthesis and replication, ultimately suppressing T. gondii proliferation and reducing intraocular inflammation. While pyrimethamine and sulfadiazine remain the cornerstone therapies for OT, it is essential to conduct vigilant monitoring due to the possibility of adverse events. These include hematological abnormalities (leukopenia, thrombocytopenia), gastrointestinal disturbances, and dermatological reactions. To mitigate these risks, weekly complete blood count monitoring is imperative throughout the treatment course. Furthermore, concomitant folinic acid supplementation is essential to counteract the antifolate effects of pyrimethamine, thereby reducing the risk of bone marrow suppression.

• #74 Clinical Care of Toxoplasmosis | Toxoplasmosis | CDC

  https://www.cdc.gov/toxoplasmosis/hcp/clinical-care/index.html

  Most people with healthy immune systems recover from toxoplasmosis without treatment. […] Drugs are available for those who require treatment. […] Currently recommended treatment drugs for toxoplasmosis target the tachyzoite stage of the parasite and do not eradicate encysted parasites in the tissues. […] Pyrimethamine, considered the most effective drug against toxoplasmosis, is a standard component of therapy. […] A second drug, such as sulfadiazine or clindamycin (if the patient has a hypersensitivity reaction to sulfa drugs), should also be included. […] 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.

• #75 Ocular Toxoplasmosis: Advances in Toxoplasma gondii Biology, Clinical Manifestations, Diagnostics, and Therapy

  https://www.mdpi.com/2076-0817/13/10/898

  Clindamycin, a lincosamide antibiotic that concentrates in ocular tissues and penetrates tissue cyst walls, can be added to the classic triple therapy as a “quadruple therapy.” This combination can effectively suppress the proliferation of T. gondii. Research has shown that the use of clindamycin alone can achieve relatively good therapeutic effects, but it is usually used in combination with other anti-Toxoplasma drugs such as pyrimethamine, sulfadiazine, or trimethoprim-sulfamethoxazole to enhance the efficacy, shorten the treatment course, and reduce the risk of recurrence. Additionally, clindamycin can also help reduce the inflammatory response in the retina caused by Toxoplasma infection, thereby improving visual prognosis. The most common adverse effects associated with clindamycin include gastrointestinal symptoms such as nausea, vomiting, and diarrhea. In rare cases, more serious side effects such as pseudomembranous colitis, a potentially life-threatening condition caused by Clostridioides difficile infection, can occur. Clinicians should closely monitor patients for the development of any adverse reactions during clindamycin therapy. If severe gastrointestinal symptoms or other serious side effects emerge, the medication should be discontinued immediately. Discontinuation of clindamycin may also be warranted in the event of severe allergic reactions, such as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) or Stevens-Johnson syndrome.

• #76 Ocular Toxoplasmosis: Advances in Toxoplasma gondii Biology, Clinical Manifestations, Diagnostics, and Therapy

  https://www.mdpi.com/2076-0817/13/10/898

  Clindamycin, a lincosamide antibiotic that concentrates in ocular tissues and penetrates tissue cyst walls, can be added to the classic triple therapy as a “quadruple therapy.” This combination can effectively suppress the proliferation of T. gondii. Research has shown that the use of clindamycin alone can achieve relatively good therapeutic effects, but it is usually used in combination with other anti-Toxoplasma drugs such as pyrimethamine, sulfadiazine, or trimethoprim-sulfamethoxazole to enhance the efficacy, shorten the treatment course, and reduce the risk of recurrence. Additionally, clindamycin can also help reduce the inflammatory response in the retina caused by Toxoplasma infection, thereby improving visual prognosis. The most common adverse effects associated with clindamycin include gastrointestinal symptoms such as nausea, vomiting, and diarrhea. In rare cases, more serious side effects such as pseudomembranous colitis, a potentially life-threatening condition caused by Clostridioides difficile infection, can occur. Clinicians should closely monitor patients for the development of any adverse reactions during clindamycin therapy. If severe gastrointestinal symptoms or other serious side effects emerge, the medication should be discontinued immediately. Discontinuation of clindamycin may also be warranted in the event of severe allergic reactions, such as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) or Stevens-Johnson syndrome.

• #77 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  Unfortunately, all drugs used in clinical practice are solely active against the tachyzoite stage of the parasite and do not demonstrate activity against cysts containing bradyzoites, the latent stage of the parasite. […] The rate of unacceptable adverse reactions, as well as the high pill burden associated with pyr-sulf, led to a quest for other therapeutic options. […] Initial, nonrandomized studies showed efficacy of clindamycin-based regimens, but the relapse rate was high for clindamycin-only maintenance therapy. […] A phase II randomized trial of pyr-sulf versus pyrimethamine-clindamycin involved 59 patients with TE. […] Based on these findings, it was concluded that pyrimethamine-clindamycin is as effective as pyr-sulf and can be used as an alternative regimen for the treatment of TE.

• #78 Drugs in development for toxoplasmosis: advances, challenges, and curr | DDDT

  https://www.dovepress.com/drugs-in-development-for-toxoplasmosis-advances-challenges-and-current-peer-reviewed-fulltext-article-DDDT

  Toxoplasma gondii causes fatal and debilitating brain and eye diseases. Medicines that are currently used to treat toxoplasmosis commonly have toxic side effects and require prolonged courses that range from weeks to more than a year. […] The challenges for developing a more effective treatment for toxoplasmosis include decreasing toxicity, achieving therapeutic concentrations in the brain and eye, shortening duration, eliminating tissue cysts from the host, safety in pregnancy, and creating a formulation that is inexpensive and practical for use in resource-poor areas of the world. […] Medicines with enhanced efficacy as well as features that address the unique aspects of toxoplasmosis have the potential to greatly improve toxoplasmosis therapy. […] Current research into new drugs developed specifically for toxoplasmosis has led to promising preclinical compounds.

• #79 A Double Hit Strategy May Provide Better Treatment for Toxoplasmosis – Center for Tropical and Emerging Global DiseasesA Double Hit Strategy May Provide Better Treatment for Toxoplasmosis – Center for Tropical and Emerging Global Diseases

  https://ctegd.uga.edu/a-double-hit-strategy-may-provide-better-treatment-for-toxoplasmosis/

  Moreno’s group proposes a double hit strategy of combining inhibitors of host and parasite pathways as a novel approach against toxoplasmosis. […] This double hit strategy may be the key to effective treatment because the parasite not only makes its own isoprenoids, but it can also import them from the host. […] This study demonstrates that early treatment is key to the cure of infection with a particular strain of T. gondii for acute infection. Since current treatments often fail to cure chronic infection Moreno and her group will next test this combination strategy in an established chronic infection mouse model. […] Furthermore, Moreno predicts that this double-hit strategy of inhibiting both host and parasite pathways will work for other intracellular Apicomplexan parasites, such as the malaria-causing Plasmodium parasite. Additional studies will be needed to test this hypothesis.

• #80 Ginger Is a Potential Therapeutic for Chronic Toxoplasmosis

  https://www.mdpi.com/2076-0817/11/7/798

  Ginger extract treatment significantly reduced cysts count in the brains of T. gondii-infected mice with a marked alleviation of edema and inflammation, and a reversal of neuronal injury. […] Currently, there are limited effective therapeutic options for toxoplasmosis with no optimal effective treatment for chronic toxoplasmosis due to poor penetration into the brain and potential side effects. […] The combination of pyrimethamine and sulfadiazine (pyr-sulf), targeting the active stage of the infection and suppressing parasite multiplication in the early stages of the disease, is the current gold standard for treating toxoplasmosis. […] Our results showed for the first time that ginger extract exhibited marked therapeutic effects in mice with chronic T. gondii infection which indicates that it can be used as a safe and effective treatment for chronic toxoplasmosis.

• #81 A Double Hit Strategy May Provide Better Treatment for Toxoplasmosis – Center for Tropical and Emerging Global DiseasesA Double Hit Strategy May Provide Better Treatment for Toxoplasmosis – Center for Tropical and Emerging Global Diseases

  https://ctegd.uga.edu/a-double-hit-strategy-may-provide-better-treatment-for-toxoplasmosis/

  Moreno’s group proposes a double hit strategy of combining inhibitors of host and parasite pathways as a novel approach against toxoplasmosis. […] This double hit strategy may be the key to effective treatment because the parasite not only makes its own isoprenoids, but it can also import them from the host. […] This study demonstrates that early treatment is key to the cure of infection with a particular strain of T. gondii for acute infection. Since current treatments often fail to cure chronic infection Moreno and her group will next test this combination strategy in an established chronic infection mouse model. […] Furthermore, Moreno predicts that this double-hit strategy of inhibiting both host and parasite pathways will work for other intracellular Apicomplexan parasites, such as the malaria-causing Plasmodium parasite. Additional studies will be needed to test this hypothesis.

• #82 Ginger Is a Potential Therapeutic for Chronic Toxoplasmosis

  https://www.mdpi.com/2076-0817/11/7/798

  Ginger extract treatment significantly reduced cysts count in the brains of T. gondii-infected mice with a marked alleviation of edema and inflammation, and a reversal of neuronal injury. […] Currently, there are limited effective therapeutic options for toxoplasmosis with no optimal effective treatment for chronic toxoplasmosis due to poor penetration into the brain and potential side effects. […] The combination of pyrimethamine and sulfadiazine (pyr-sulf), targeting the active stage of the infection and suppressing parasite multiplication in the early stages of the disease, is the current gold standard for treating toxoplasmosis. […] Our results showed for the first time that ginger extract exhibited marked therapeutic effects in mice with chronic T. gondii infection which indicates that it can be used as a safe and effective treatment for chronic toxoplasmosis.

• #83 Study identifies six drugs that can be repurposed for treatment of toxoplasmosis

  https://agencia.fapesp.br/study-identifies-six-drugs-that-can-be-repurposed-for-treatment-of-toxoplasmosis/49885

  Scientists are looking for new ways to treat toxoplasmosis, an infectious disease that affects more than a third of the world population. […] The group screened 160 existing drugs to explore their potential repurposing to combat toxoplasmosis. […] We identified six compounds that are at least 30 times more deadly for the toxoplasmosis parasite than for the host cells, said Juliana Quero Reimo, last author of the article. […] We tested it on mice with chronic toxoplasmosis and found it to be effective, leading to a significant reduction in brain parasite load, said Reimo, a professor of parasitology and thesis advisor for FMJs program of graduate studies in health sciences. […] More trials are needed before any of the drugs can be repurposed for the treatment of toxoplasmosis, but the results so far are highly promising, she added.

• #84 Ginger Is a Potential Therapeutic for Chronic Toxoplasmosis

  https://www.mdpi.com/2076-0817/11/7/798

  Ginger extract treatment significantly reduced cysts count in the brains of T. gondii-infected mice with a marked alleviation of edema and inflammation, and a reversal of neuronal injury. […] Currently, there are limited effective therapeutic options for toxoplasmosis with no optimal effective treatment for chronic toxoplasmosis due to poor penetration into the brain and potential side effects. […] The combination of pyrimethamine and sulfadiazine (pyr-sulf), targeting the active stage of the infection and suppressing parasite multiplication in the early stages of the disease, is the current gold standard for treating toxoplasmosis. […] Our results showed for the first time that ginger extract exhibited marked therapeutic effects in mice with chronic T. gondii infection which indicates that it can be used as a safe and effective treatment for chronic toxoplasmosis.

• #85 Ginger Is a Potential Therapeutic for Chronic Toxoplasmosis

  https://www.mdpi.com/2076-0817/11/7/798

  Based on the limited treatment options and potential side effects, several research groups have considered the use of medicinal plant extracts as potential alternative and safe therapeutics for toxoplasmosis. […] Our results demonstrated that ginger extract treatment resulted in a significant reduction in the number of T. gondii cysts in the brains of infected mice compared with infected untreated animals. […] In the present study, we evaluated the therapeutic potential of ethanolic extract of ginger in a chronic toxoplasmosis murine model induced by oral infection with an Me49 strain of T. gondii. […] Ginger extract treatment demonstrated higher therapeutic efficacy because liver tissues of spiramycin-treated animals still showed a portal tract expansion with inflammatory cells and a mild degree of hydropic degeneration.

• #86 Toxoplasmosis Treatment & Management: Approach Considerations, Emergency Department Care, Deterrence and Prevention

  https://emedicine.medscape.com/article/229969-treatment

  Care of the patient in the emergency department should be specific to the presenting manifestations of the disease. […] Because the symptoms associated with acute toxoplasmosis are nonspecific and dependent on the tissues involved, emergency providers must be vigilant and include other infectious and noninfectious etiologies in their differential diagnoses. […] Currently, the only effective vaccine against toxoplasmosis is Toxovax, which contains a live attenuated S48 strain and controls congenital infection in sheep. […] Toxovax decreases the abortion rate but does not eradicate T gondii completely. Nevertheless, it is expensive and may be changed into a pathogenic form; for this reason, it is not appropriate for human use. Unfortunately, no licensed vaccine is yet available for humans.

• #87 Toxoplasmosis Treatment & Management: Approach Considerations, Emergency Department Care, Deterrence and Prevention

  https://emedicine.medscape.com/article/229969-treatment

  Care of the patient in the emergency department should be specific to the presenting manifestations of the disease. […] Because the symptoms associated with acute toxoplasmosis are nonspecific and dependent on the tissues involved, emergency providers must be vigilant and include other infectious and noninfectious etiologies in their differential diagnoses. […] Currently, the only effective vaccine against toxoplasmosis is Toxovax, which contains a live attenuated S48 strain and controls congenital infection in sheep. […] Toxovax decreases the abortion rate but does not eradicate T gondii completely. Nevertheless, it is expensive and may be changed into a pathogenic form; for this reason, it is not appropriate for human use. Unfortunately, no licensed vaccine is yet available for humans.

• #88 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  In general, induction therapy should be continued for at least 6 weeks. […] Since the currently available anti-T. gondii therapy cannot eradicate the protozoan, induction therapy should be followed by maintenance therapy as long as the patient remains significantly immunosuppressed. […] The risk of relapse is more than 50% in the absence of maintenance therapy. […] While pyr-sulf combination therapy is the current gold standard for the treatment of acute TE in HIV patients, pyrimethamine-clindamycin and TMP-SMX also seem to be similarly effective; however, no regimen has been found to be superior to pyr-sulf. […] The choice of therapy should be guided by drug availability, tolerability, and the ability of patients to take medications enterally. […] The clinical experience with other regimens (atovaquone monotherapy, atovaquone with pyrimethamine or sulfadiazine, and pyrimethamine with azithromycin or clarithromycin) is limited, and these should be used only in the absence of alternatives. […] Treatment should be started as soon as feasible after birth and continued for at least 1 year.

• #89 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  In general, induction therapy should be continued for at least 6 weeks. […] Since the currently available anti-T. gondii therapy cannot eradicate the protozoan, induction therapy should be followed by maintenance therapy as long as the patient remains significantly immunosuppressed. […] The risk of relapse is more than 50% in the absence of maintenance therapy. […] While pyr-sulf combination therapy is the current gold standard for the treatment of acute TE in HIV patients, pyrimethamine-clindamycin and TMP-SMX also seem to be similarly effective; however, no regimen has been found to be superior to pyr-sulf. […] The choice of therapy should be guided by drug availability, tolerability, and the ability of patients to take medications enterally. […] The clinical experience with other regimens (atovaquone monotherapy, atovaquone with pyrimethamine or sulfadiazine, and pyrimethamine with azithromycin or clarithromycin) is limited, and these should be used only in the absence of alternatives. […] Treatment should be started as soon as feasible after birth and continued for at least 1 year.

• #90 How to Diagnose & Treat Ocular Toxoplasmosis

  https://www.reviewofophthalmology.com/article/how-to-diagnose-treat-ocular-toxoplasmosis

  In immunocompromised patients, the treatment regimen is partially modified. […] Lifetime maintenance therapy including either a lower dosage of pyrimethamine combined with sulfadiazine or clindamycin or trimethoprim/sulfamethoxazole is crucial to prevent relapse and dissemination of the infection. […] In summary, ocular toxoplasmosis is the most common cause of infectious posterior uveitis in many countries. Although there is no effective therapy to eradicate the organism, treatment is accompanied by resolution of active infection in the vast majority of cases. Recent studies have demonstrated that this goal may be achieved with safer regimens, such as oral trimethoprim/sulfamethoxazole or intravitreal clindamycin/dexamethasone.

• #91 Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6148195/

  In general, induction therapy should be continued for at least 6 weeks. […] Since the currently available anti-T. gondii therapy cannot eradicate the protozoan, induction therapy should be followed by maintenance therapy as long as the patient remains significantly immunosuppressed. […] The risk of relapse is more than 50% in the absence of maintenance therapy. […] While pyr-sulf combination therapy is the current gold standard for the treatment of acute TE in HIV patients, pyrimethamine-clindamycin and TMP-SMX also seem to be similarly effective; however, no regimen has been found to be superior to pyr-sulf. […] The choice of therapy should be guided by drug availability, tolerability, and the ability of patients to take medications enterally. […] The clinical experience with other regimens (atovaquone monotherapy, atovaquone with pyrimethamine or sulfadiazine, and pyrimethamine with azithromycin or clarithromycin) is limited, and these should be used only in the absence of alternatives. […] Treatment should be started as soon as feasible after birth and continued for at least 1 year.

• #92 How to Diagnose & Treat Ocular Toxoplasmosis

  https://www.reviewofophthalmology.com/article/how-to-diagnose-treat-ocular-toxoplasmosis

  In immunocompromised patients, the treatment regimen is partially modified. […] Lifetime maintenance therapy including either a lower dosage of pyrimethamine combined with sulfadiazine or clindamycin or trimethoprim/sulfamethoxazole is crucial to prevent relapse and dissemination of the infection. […] In summary, ocular toxoplasmosis is the most common cause of infectious posterior uveitis in many countries. Although there is no effective therapy to eradicate the organism, treatment is accompanied by resolution of active infection in the vast majority of cases. Recent studies have demonstrated that this goal may be achieved with safer regimens, such as oral trimethoprim/sulfamethoxazole or intravitreal clindamycin/dexamethasone.

• #93 Toxoplasmosis Center – UChicago Medicine

  https://www.uchicagomedicine.org/conditions-services/ophthalmology/toxoplasmosis-center

  The University of Chicago Medicine has developed a unique center to help babies, children and adults affected by toxoplasmosis. […] For patients with toxoplasmosis, we offer the latest treatment options to improve their quality of life. […] We provide access to the latest advancements in toxoplasmosis treatment to offer our patients the best possible care. […] Treatment can prevent transmission of the parasite from mother to child. When diagnosed and treated early, treatment can also prevent the infection’s adverse effects for a baby or for older persons with brain or eye disease. […] Medicines currently used to treat toxoplasmosis have side effects. No medicines currently available can eliminate the dormant parasites from the body, so toxoplasmosis may recur. However, there is promise for both improved medicines and a vaccine. […] There is also encouraging progress being made toward discovery of improved medicines.

• #94 Toxoplasmosis Center – UChicago Medicine

  https://www.uchicagomedicine.org/conditions-services/ophthalmology/toxoplasmosis-center

  The University of Chicago Medicine has developed a unique center to help babies, children and adults affected by toxoplasmosis. […] For patients with toxoplasmosis, we offer the latest treatment options to improve their quality of life. […] We provide access to the latest advancements in toxoplasmosis treatment to offer our patients the best possible care. […] Treatment can prevent transmission of the parasite from mother to child. When diagnosed and treated early, treatment can also prevent the infection’s adverse effects for a baby or for older persons with brain or eye disease. […] Medicines currently used to treat toxoplasmosis have side effects. No medicines currently available can eliminate the dormant parasites from the body, so toxoplasmosis may recur. However, there is promise for both improved medicines and a vaccine. […] There is also encouraging progress being made toward discovery of improved medicines.

• #95 Drugs in development for toxoplasmosis: advances, challenges, and curr | DDDT

  https://www.dovepress.com/drugs-in-development-for-toxoplasmosis-advances-challenges-and-current-peer-reviewed-fulltext-article-DDDT

  Toxoplasma gondii causes fatal and debilitating brain and eye diseases. Medicines that are currently used to treat toxoplasmosis commonly have toxic side effects and require prolonged courses that range from weeks to more than a year. […] The challenges for developing a more effective treatment for toxoplasmosis include decreasing toxicity, achieving therapeutic concentrations in the brain and eye, shortening duration, eliminating tissue cysts from the host, safety in pregnancy, and creating a formulation that is inexpensive and practical for use in resource-poor areas of the world. […] Medicines with enhanced efficacy as well as features that address the unique aspects of toxoplasmosis have the potential to greatly improve toxoplasmosis therapy. […] Current research into new drugs developed specifically for toxoplasmosis has led to promising preclinical compounds.

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