title: Treatment-ladder and genetic characterisation of parasites in refractory giardiasis after an outbreak in Norway.
abstract: OBJECTIVE
  To evaluate the efficacy of a treatment ladder in metronidazole-refractory giardiasis, and to compare genetic characteristics of the parasites.
  
  
  METHODS
  A clinical observational study was carried out in 38 adult patients with metronidazole-refractory giardiasis, during an outbreak in Norway with more than 1200 cases. All patients were treated with albendazole in combination with metronidazole. Those who failed were treated with paromomycin. Those who failed on paromomycin were treated with quinacrine in combination with metronidazole. Giardia isolates from 17 patients were characterised by PCR and sequencing at two separate genes.
  
  
  RESULTS
  Metronidazole in combination with albendazole was effective in 30 (79%) out of 38 patients. Paromomycin was effective in three out of six patients. Quinacrine in combination with metronidazole was effective in 3 patients. Molecular characterisation of the Giardia isolates revealed that these parasites were identical at two different gene segments, while sequence profiles from isolates at the peak of the outbreak were more heterogenous.
  
  
  CONCLUSIONS
  Albendazole and quinacrine both in combination with metronidazole were effective in treating metronidazole-refractory giardiasis in this cohort. Paromomycin was less effective. Particular Giardia sub-genotypes may have been associated with the treatment-refractory giardiasis in these patients, although other undefined factors are probably also of importance.
authors.affiliation: National Centre for Tropical Medicine and Imported Infectious Diseases, Haukeland University Hospital, 5021 Bergen, Norway. kristine.moerch@helse-bergen.no
authors.forename: K
authors.initials: K
authors.lastname: Mørch
authors.forename: K
authors.initials: K
authors.lastname: Hanevik
authors.forename: L J
authors.initials: LJ
authors.lastname: Robertson
authors.forename: E A
authors.initials: EA
authors.lastname: Strand
authors.forename: N
authors.initials: N
authors.lastname: Langeland
mesh_terms: D000293:Adolescent; D000328:Adult; D015766:Albendazole / Q000008:administration & dosage* / Q000009:adverse effects; D000465:Algorithms; D000818:Animals; D000962:Antimalarials / Q000008:administration & dosage; D000981:Antiprotozoal Agents / Q000008:administration & dosage* / Q000009:adverse effects; D004196:Disease Outbreaks; D004359:Drug Therapy, Combination; D005243:Feces / Q000469:parasitology; D005260:Female; D005872:Giardia / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification; D005873:Giardiasis / Q000097:blood / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008795:Metronidazole / Q000008:administration & dosage* / Q000009:adverse effects; D008875:Middle Aged; D009664:Norway / Q000453:epidemiology; D010303:Paromomycin / Q000008:administration & dosage*; D016133:Polymerase Chain Reaction; D011796:Quinacrine / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D000962:Antimalarials; D000981:Antiprotozoal Agents; D008795:Metronidazole; D010303:Paromomycin; D015766:Albendazole; D011796:Quinacrine