Which medications are used in the treatment of babesiosis?

Updated: Apr 01, 2021
  • Author: Rachel E Strength, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

In asymptomatic, immunocompetent patients with positive results from peripheral smears or polymerase chain reaction (PCR) testing, treatment is not recommended. If a patient is diagnosed after symptoms have resolved, they should not receive treatment unless organisms are seen on peripheral smear for more than one month from the time of acute illness. PCR assays are not recommended for monitoring parasitemia in this patient group since relapse rarely occurs. [3]

In symptomatic, immunocompetent patients, antimicrobial therapy should be started after confirmed diagnosis to reduce the level of parasitemia. A drug regimen consisting of atovaquone and azithromycin is now first-line treatment and has been shown to be effective.25 Clindamycin plus quinine is an alternative regimen, but it results in far more adverse effects.  

Per the IDSA, the recommended regimens in adults are as follows [3] :

Ambulatory adults with mild-moderate disease:

  • First line: atovaquone 750 mg PO q12h plus azithromycin 500 mg PO on day one, followed by 250 mg PO q24h for 7-10 days
  • Alternative treatment: clindamycin 600 mg PO q8h plus quinine sulfate 542 mg base (equal to 650 mg salt) PO q6-8h for 7-10 days

Hospitalized adults with acute severe disease:

  • First line: atovaquone 750 mg PO q12h plus azithromycin 500-1000 mg IV q24h until symptoms improve, then convert to step-down therapy 
  • Alternative treatment: Clindamycin 600 mg IV q6h plus quinine sulfate 542 mg base (equal to 650 mg salt) PO q6-8h until symptoms improve, then convert to step-down therapy 

Hospitalized adults, step-down therapy:

  • First line: atovaquone 750 mg PO q12h plus azithromycin 250-500 mg PO q24h; total course of therapy is usually 7-10 days.  Consider using a higher dose of azithromycin (500-1000 mg) in immunocompromised patients.
  • Alternative treatment: clindamycin 600 mg PO q8h plus quinine sulfate 542 mg base (equal to 650 mg salt) PO q6-8h; total course of therapy is usually 7-10 days.

Relapse is more common in immunocompromised patients.  If a patient experiences relapse, the IDSA notes that the following regimens have been used with limited evidence:

  • Atovaquone + azithromycin + clindamycin
  • Atovaquone + clindamycin
  • Atovaquone/proguanil + azithromycin
  • Atovaquone + azithromycin + clindamycin + quinine
  • With relapse, higher doses of azithromycin (500 or 1000 mg daily) have been used. [3]

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