title: Combination therapy in the management of giardiasis: What laboratory and clinical studies tell us, so far.
abstract: Treatment failures in patients suffering from giardiasis are not uncommon feature. The most frequent approach in these cases is to treat these patients with longer repeated courses and/or higher doses of the primary therapy, or using drugs from a different class to avoid potential cross-resistance. However, a higher rate of adverse events may limit this strategy. In this context, combination therapy (CT) is emerging as a valuable option against refractory giardiasis. In the attempt to evaluate the benefits of CT, a number of experimental studies, clinical series, and randomized clinical trials (RCTs), as well as several veterinary studies have been performed, with varying results. Here, we present a critical analysis of the available information regarding CT for the treatment of Giardia infection, as well as the authors' opinion with respect to its use. RCTs of combination therapy are limited and the optimal combinations and administration strategies need yet to be clarified. Analyses of the cost-effectiveness and RCTs of CTs for Giardia infection are required to assess the role of these drugs for the control of giardiasis, mainly in the case of treatment failures linked to suspected drug tolerance are the case.
authors.affiliation: Department of Microbiology and Parasitology, Academic Paediatric Hospital "Pedro Borrás", F. No. 616, esquina a 27, Plaza, La Habana 10400, Cuba; Working Group on Zoonoses, International Society for Chemotherapy, Aberdeen, United Kingdom; Committee on Clinical Parasitology, Panamerican Association for Infectious Diseases (Asociación Panamericana de Infectología), Cuba. Electronic address: escobedo@infomed.sld.cu.
authors.forename: Angel A
authors.initials: AA
authors.lastname: Escobedo
authors.affiliation: Department of Infectious, Parasitic and Immunomediated Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy. Electronic address: marco.lalle@iss.it.
authors.forename: Marco
authors.initials: M
authors.lastname: Lalle
authors.affiliation: University of Nova Gorica, Vipavska 13, 5000 Nova Gorica, Slovenia.
authors.forename: Nana I
authors.initials: NI
authors.lastname: Hrastnik
authors.affiliation: Working Group on Zoonoses, International Society for Chemotherapy, Aberdeen, United Kingdom; Committee on Clinical Parasitology, Panamerican Association for Infectious Diseases (Asociación Panamericana de Infectología), Cuba; Research Group Public Health and Infection, Faculty of Health Sciences, Universidad Tecnológica de Pereira (UTP), Pereira, Risaralda, Colombia; Committee on Zoonoses and Hemorrhagic Fevers of the Colombian Association of Infectious Diseases (Asociación Colombiana de Infectología, ACIN), Bogotá, Colombia.
authors.forename: Alfonso J
authors.initials: AJ
authors.lastname: Rodríguez-Morales
authors.affiliation: Centre for Infection Prevention and Management, Imperial College London, Faculty of Medicine, Commonwealth Building, Du Cane Road, London W12 0NN, United Kingdom.
authors.forename: Enrique
authors.initials: E
authors.lastname: Castro-Sánchez
authors.affiliation: Committee on Clinical Parasitology, Panamerican Association for Infectious Diseases (Asociación Panamericana de Infectología), Cuba; Institute of Infectious Diseases "Emilio Ribas", Rua Zacarias de Gois, 966/41, 04610-002 São Paulo, SP, Brazil.
authors.forename: Sérgio
authors.initials: S
authors.lastname: Cimerman
authors.affiliation: Committee on Clinical Parasitology, Panamerican Association for Infectious Diseases (Asociación Panamericana de Infectología), Cuba; Analisys and Health Trends Unit, Unidad Municipal de Higiene, Epidemiología y Microbiología, Calle 8 esquina a 17, Plaza, La Habana, Cuba.
authors.forename: Pedro
authors.initials: P
authors.lastname: Almirall
authors.affiliation: Faculty of Medicine "Manuel Fajardo", Zapata esquina a C, Plaza, La Habana, CP 10400, Cuba.
authors.forename: Jony
authors.initials: J
authors.lastname: Jones
mesh_terms: D000818:Animals; D000981:Antiprotozoal Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D005873:Giardiasis / Q000188:drug therapy*; D006801:Humans
chemical_list: D000981:Antiprotozoal Agents
keywords: 5-Nitroimidazoles; Albendazole; Combination therapy; Giardia; Giardiasis; Metronidazole; Nitazoxanide; Quinacrine; Tinidazole