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Krause PJ, Auwaerter PG, Bannuru RR, Branda JA, Falck-Ytter YT, Lantos PM, Lavergne V, Meissner HC, Osani MC, Rips JG, Sood SK, Vannier E, Vaysbrot EE, Wormser GP. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA): 2020 Guideline on Diagnosis and Management of Babesiosis. Clin Infect Dis 2021; 72:e49-e64. [PMID: 33252652 DOI: 10.1093/cid/ciaa1216] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 11/12/2022] Open
Abstract
The purpose of this guideline is to provide evidence-based guidance for the most effective strategies for the diagnosis and management of babesiosis. The diagnosis and treatment of co-infection with babesiosis and Lyme disease will be addressed in a separate Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) guideline [1]. Recommendations for the diagnosis and treatment of human granulocytic anaplasmosis can be found in the recent rickettsial disease guideline developed by the Centers for Disease Control and Prevention [2]. The target audience for the babesiosis guideline includes primary care physicians and specialists caring for this condition, such as infectious diseases specialists, emergency physicians, intensivists, internists, pediatricians, hematologists, and transfusion medicine specialists.
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Affiliation(s)
- Peter J Krause
- Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raveendhara R Bannuru
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yngve T Falck-Ytter
- Case Western Reserve University and VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Valéry Lavergne
- Research Center CIUSSS NIM, University of Montreal, Quebec, Canada
| | - H Cody Meissner
- Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Mikala C Osani
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Sunil K Sood
- Zucker School of Medicine and Cohen Children's Medical Center, Northwell Health, New York, USA
| | - Edouard Vannier
- Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Elizaveta E Vaysbrot
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
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Abstract
INTRODUCTION Human babesiosis is reported throughout the world and is endemic in the northeastern and northern Midwestern United States and northeastern China. Transmission is primarily through hard bodied ticks. Most cases of severe disease occur in immunocompromised individuals and may result in prolonged relapsing disease or death. AREAS COVERED We provide a summary of evidence supporting current treatment recommendations for immunocompetent and immunocompromised individuals experiencing babesiosis. EXPERT OPINION Most cases of human babesiosis are successfully treated with atovaquone and azithromycin or clindamycin and quinine. Severe disease may require prolonged treatment.
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Affiliation(s)
- Robert P Smith
- Division of Infectious Diseases, Maine Medical Center, Portland, Maine; Tufts University School of Medicine , Boston, MA, USA
| | - Klaus-Peter Hunfeld
- Institute for Laboratory Medicine, Microbiology & Infection Control, Northwest Medical Centre, Medical Faculty, Goethe University , Frankfurt/Main, Germany
| | - Peter J Krause
- Yale School of Public Health and Yale School of Medicine , New Haven, CT, USA
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Hematologic Aspects of Parasitic Diseases. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00158-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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Sanchez E, Vannier E, Wormser GP, Hu LT. Diagnosis, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: A Review. JAMA 2016; 315:1767-77. [PMID: 27115378 PMCID: PMC7758915 DOI: 10.1001/jama.2016.2884] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Lyme disease, human granulocytic anaplasmosis (HGA), and babesiosis are emerging tick-borne infections. OBJECTIVE To provide an update on diagnosis, treatment, and prevention of tick-borne infections. EVIDENCE REVIEW Search of PubMed and Scopus for articles on diagnosis, treatment, and prevention of tick-borne infections published in English from January 2005 through December 2015. FINDINGS The search yielded 3550 articles for diagnosis and treatment and 752 articles for prevention. Of these articles, 361 were reviewed in depth. Evidence supports the use of US Food and Drug Administration-approved serologic tests, such as an enzyme immunoassay (EIA), followed by Western blot testing, to diagnose extracutaneous manifestations of Lyme disease. Microscopy and polymerase chain reaction assay of blood specimens are used to diagnose active HGA and babesiosis. The efficacy of oral doxycycline, amoxicillin, and cefuroxime axetil for treating Lyme disease has been established in multiple trials. Ceftriaxone is recommended when parenteral antibiotic therapy is recommended. Multiple trials have shown efficacy for a 10-day course of oral doxycycline for treatment of erythema migrans and for a 14-day course for treatment of early neurologic Lyme disease in ambulatory patients. Evidence indicates that a 10-day course of oral doxycycline is effective for HGA and that a 7- to 10-day course of azithromycin plus atovaquone is effective for mild babesiosis. Based on multiple case reports, a 7- to 10-day course of clindamycin plus quinine is often used to treat severe babesiosis. A recent study supports a minimum of 6 weeks of antibiotics for highly immunocompromised patients with babesiosis, with no parasites detected on blood smear for at least the final 2 weeks of treatment. CONCLUSIONS AND RELEVANCE Evidence is evolving regarding the diagnosis, treatment, and prevention of Lyme disease, HGA, and babesiosis. Recent evidence supports treating patients with erythema migrans for no longer than 10 days when doxycycline is used and prescription of a 14-day course of oral doxycycline for early neurologic Lyme disease in ambulatory patients. The duration of antimicrobial therapy for babesiosis in severely immunocompromised patients should be extended to 6 weeks or longer.
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Affiliation(s)
- Edgar Sanchez
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Edouard Vannier
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Gary P. Wormser
- Division of Infectious Diseases, New York Medical College, Valhalla, New York
| | - Linden T. Hu
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts
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Abstract
Babesiosis is a protozoan parasitic infection affecting humans and animals. These infections are commonly transmitted by various species of Ixodes ticks depending upon the geographical location. They can also be transmitted by packed cell transfusion and transplacental route from mother to child. Various species have been reported to cause human infections, of which Babesia microti is the most common species reported globally. Usually, Babesia infections are asymptomatic or mild, but can be severe/life-threatening in immunosuppressed or splenectomized individuals. A high index of clinical suspicion in residents of endemic areas or individuals who had a recent travel history to such areas, with laboratory confirmation can guide an early institution of appropriate antimicrobial therapy, thereby preventing complications and death.
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Affiliation(s)
- Subhash Chandra Parija
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Tamil Nadu, India
| | - Dinoop Kp
- Department of Microbiology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Hrudya Venugopal
- Department of General Medicine, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India
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Affiliation(s)
- Edouard Vannier
- Department of Medicine, Tufts Medical Center and Tufts University School of Medicine, Boston, USA
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Abstract
Human babesiosis is an emerging tick-borne infectious disease caused by intraerythrocytic protozoan species of the genus Babesia with many clinical features similar to those of malaria. Over the last 50 years, the epidemiology of human babesiosis has changed from a few isolated cases to the establishment of endemic areas in the northeastern and midwestern United States. Episodic cases are reported in Europe, Asia, Africa, and South America. The severity of infection ranges from asymptomatic infection to fulminant disease resulting in death, although the majority of healthy adults experience a mild-to-moderate illness. People over the age of 50 years and immunocompromised individuals are at the highest risk of severe disease, including those with malignancy, HIV, lacking a spleen, or receiving immunosuppressive drugs. Asymptomatic carriers present a blood safety risk when they donate blood. Definitive diagnosis of babesial infection generally is made by microscopic identification of the organism on thin blood smear, amplification of Babesia DNA using PCR, and detection of Babesia antibody in acute and convalescent sera. Specific antimicrobial therapy consists of atovaquone and azithromycin or clindamycin and quinine. Exchange transfusion is used in severe cases. The use of multiple prevention strategies is recommended and consists of personal, residential, and community approaches.
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Cunha BA, Nausheen S, Szalda D. Pulmonary complications of babesiosis: case report and literature review. Eur J Clin Microbiol Infect Dis 2007; 26:505-8. [PMID: 17558489 PMCID: PMC7102213 DOI: 10.1007/s10096-007-0325-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Reported here is a rare case of babesiosis with pulmonary complications followed by a review of the literature. Babesiosis presents clinically as a malaria-like illness with fever, chills, headache, fatigue with lymphopenia, atypical lymphocytes, mildly or transiently elevated serum transaminases, thrombocytopenia, and increased lactate dehydrogenase (LDH) levels. The diagnosis of babesiosis is based on identification of Babesia spp. on a peripheral blood smear. Babesiosis is usually mild in normal hosts, but it may be severe or even fatal in asplenic patients. Pulmonary manifestations are rare in babesiosis, but non-cardiogenic pulmonary edema (NCPE) is the most frequent manifestation. NCPE in babesiosis does not appear to be related to the degree of parasitemia or splenic function and its onset may be early or late. NCPE usually resolves rapidly with supportive treatment; it is rarely fatal. Clinicians should suspect NCPE in patients with babesiosis who acutely develop shortness of breath and have chest radiograph findings compatible with acute pulmonary edema without cardiomegaly or pleural effusions.
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Affiliation(s)
- B A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, New York, NY 11501, USA.
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Stowell CP, Gelfand JA, Shepard JAO, Kratz A. Case records of the Massachusetts General Hospital. Case 17-2007. A 25-year-old woman with relapsing fevers and recent onset of dyspnea. N Engl J Med 2007; 356:2313-9. [PMID: 17538091 DOI: 10.1056/nejmcpc079011] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt L, Fish D, Dumler JS, Nadelman RB. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089-134. [PMID: 17029130 DOI: 10.1086/508667] [Citation(s) in RCA: 1257] [Impact Index Per Article: 69.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 08/21/2006] [Indexed: 12/19/2022] Open
Abstract
Evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis were prepared by an expert panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 31[Suppl 1]:1-14). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. For each of these Ixodes tickborne infections, information is provided about prevention, epidemiology, clinical manifestations, diagnosis, and treatment. Tables list the doses and durations of antimicrobial therapy recommended for treatment and prevention of Lyme disease and provide a partial list of therapies to be avoided. A definition of post-Lyme disease syndrome is proposed.
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Affiliation(s)
- Gary P Wormser
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, NY 10595, USA.
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Abstract
Babesiosis is caused by a haemotropic protozoal parasite of the genus Babesia, member of the phylum Apicomplexa and transmitted by the bite of an infected tick. There are many Babesia species affecting livestock, dogs, horses and rodents which are of economic significance. Infections can occur without producing symptoms, but babesiosis may also be severe and sometimes fatal caused by the intraerythrocytic parasite development. The disease can cause fever, fatigue and haemolytic anemia lasting from several days to several months. There are a number of effective babesiacides, but imidocarb dipropionate (which consistently clears the parasitaemia; often the only available drug on the market) and diminazene aceturate are the most widely used. Some Babesia spp. can infect humans, particularly Babesia microti and Babesia divergens, and human babesiosis is a significant emerging tick-borne zoonotic disease. Clinical manifestations differ markedly between European and North American diseases. In clinical cases, a combination of clindamycin and quinine is administered as the standard treatment, but also administration of atovaquone-azithromycin is successful. Supportive therapy such as intravenous fluids and blood transfusions are employed when necessary. More specific fast-acting new treatments for babesiosis have now to be developed. This should be facilitated by the knowledge of the Babesia spp. genome and increased interest for this malaria-like parasite.
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Affiliation(s)
- Henri J Vial
- Dynamique Moléculaire des Interactions Membranaires, UMR 5539 CNRS/Université Montpellier II, Case 107, Place Eugène bataillon, F-34095 Montpellier Cedex 5, France.
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12
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Abstract
Human infections with Babesia species, in particular Babesia microti, are tick-borne illnesses that are being recognised with increased frequency. Coinfection with ehrlichiosis and Lyme disease is also being recognised as an important feature of these tick-borne illnesses. Despite the superficial resemblance of Babesia to malaria, these piroplasms do not respond to chloroquine or other similar drugs. However, the treatment of babesiosis using a clindamycin-quinine combination has been successful. Data in animal models and case-reports in humans have suggested that an atovaquone-azithromycin combination is also effective. This was confirmed in a recent prospective, open, randomised trial of clindamycin-quinine versus azithromycin-atovaquone. This paper reviews the literature on the treatment of human babesiosis and the animal models of these human pathogens.
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Affiliation(s)
- Louis M Weiss
- Division of Infectious Diseases, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Room 504 Forchheimer Building, Bronx, New York, 10461, USA.
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Affiliation(s)
- Cynthia J Mollen
- Division of Emergency Medicine, and Divisions of Immunologic and Infectious Diseases, General Pediatrics, and Emergency Medicine, The Children's Hospital of Philadelphia, PA
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