Toxoplasmosis
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
occupational exposure
HIV-positive with CD4+ T lymphocyte count <100
seronegative recipients of solid organs from seropositive donors; seropositive recipients of allogeneic haematopoietic stem cell transplant
newborns: confirmed or highly suspected congenital disease
non-pregnant adults and children: confirmed or suspected disease
pregnant: with seroconversion
immunocompromised: following symptomatic disease
prophylactic pyrimethamine + sulfadiazine + calcium folinate
This group is composed of patients exposed to Toxoplasma gondii by contact with infected blood or cell cultures.
Anti-Toxoplasma immunoglobulin G should be checked immediately to identify those at risk for acute infection.
All seronegative exposed patients or those with unknown serology should be treated. Most experts would treat all individuals with a definite exposure.
For those with no detectable antibodies, treatment is given for 4 weeks and serology repeated. If seroconversion is documented, patients should be followed clinically.
If seropositive at onset of treatment or known positive prior to exposure, the patient is probably partially protected. Most experts would treat high inoculum deep exposures of a virulent type I strain for 2 weeks.
Primary options
pyrimethamine: adults: 50-75 mg orally once daily
and
sulfadiazine: adults: 1000 mg orally four times daily
and
calcium folinate: adults: 10-25 mg orally once daily
prophylactic trimethoprim/sulfamethoxazole
Given to prevent symptomatic disease.
For all patients with HIV and CD4+ T lymphocyte counts <100 cells/microlitre and children <6 years old with CD4 cell percentage <15% who have positive serologies.[24]Department of Health and Human Services, Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. May 2024 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf [49]Department of Health and Human Services, Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV. Aug 2023 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/pediatric-oi/guidelines-pediatric-oi.pdf Primary prophylaxis can be discontinued for adolescent and adult patients taking antiretroviral therapy with CD4+ T lymphocyte counts between 100 and 200 cells/microlitre if the HIV RNA plasma viral load remains below the limit of detection for at least 3 to 6 months.[24]Department of Health and Human Services, Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. May 2024 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf
Primary options
trimethoprim/sulfamethoxazole: children: 150 mg/square metre of body surface area orally once daily; adults: 160 mg orally once daily
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim component. Other dose regimens are also recommended in guidelines as alternative options.
non-sulfonamide prophylactic regimen
Second-line options for prophylaxis for patients with HIV who are allergic to, or severely intolerant of, sulfonamides.[24]Department of Health and Human Services, Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. May 2024 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf
Primary options
dapsone: children >1 month of age: 2 mg/kg (or 15 mg/square metre of body surface area) orally once daily, maximum 25 mg/day; adults: 50 mg orally once daily
and
pyrimethamine: children >1 month of age: 1 mg/kg (or 15 mg/square metre of body surface area) orally once daily, maximum 25 mg/day; adults: 50 mg orally once weekly
and
calcium folinate: children >1 month of age: 5 mg orally every three days; adults: 25 mg orally once weekly
Secondary options
dapsone: adults: 200 mg orally once weekly
and
pyrimethamine: adults: 75 mg orally once weekly
and
calcium folinate: adults: 25 mg orally once weekly
Tertiary options
atovaquone: children 1-3 months of age and >24 months of age: 30 mg/kg orally once daily; children 4-24 months of age: 45 mg/kg orally once daily; adults: 1500 mg orally once daily
OR
atovaquone: children 4-24 months of age: 45 mg/kg orally once daily; adults: 1500 mg orally once daily
and
pyrimethamine: children 4-24 months of age: 1 mg/kg (or 15 mg/square metre of body surface area) orally once daily, maximum 25 mg/day; adults: 25 mg orally once daily
and
calcium folinate: children 4-24 months of age: 5 mg orally every three days; adults: 10 mg orally once daily
prophylactic trimethoprim/sulfamethoxazole
Given to prevent symptomatic disease.
There are very few data supporting prophylactic regimens other than trimethoprim/sulfamethoxazole for toxoplasmosis in the transplant population.[25]Hoz RM La, Morris MI; Infectious Diseases Community of Practice of the American Society of Transplantation. Tissue and blood protozoa including toxoplasmosis, Chagas disease, leishmaniasis, Babesia, Acanthamoeba, Balamuthia, and Naegleria in solid organ transplant recipients - guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13546. http://www.ncbi.nlm.nih.gov/pubmed/30900295?tool=bestpractice.com Any treatment decisions should be made in consultation with physicians specialising in transplantation and infectious diseases.
After completing initial treatment, patients should continue to receive secondary prophylaxis to prevent reactivation of disease, for as long as they remain immunocompromised. The optimal duration for prophylaxis after transplant is not known, and it is sometimes continued for life. Lifelong prophylaxis is recommended for high-risk heart transplant recipients (where the donor is Toxoplasma immunoglobulin [Ig] G positive and the recipient is Toxoplasma IgG negative).
Primary options
trimethoprim/sulfamethoxazole: children: consult specialist for guidance on dose; adults: 160 mg orally three times weekly or 80 mg once daily for 3 months, followed by 160 mg once daily thereafter
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim component.
non-sulfonamide prophylactic regimen
In sulfa-allergic patients who are not deficient in glucose-6-phosphate dehydrogenase, an alternative prophylaxis regimen is dapsone plus pyrimethamine and calcium folinate. If there is a contraindication to trimethoprim/sulfamethoxazole, consult an infectious diseases specialist for advice on alternative regimens.[25]Hoz RM La, Morris MI; Infectious Diseases Community of Practice of the American Society of Transplantation. Tissue and blood protozoa including toxoplasmosis, Chagas disease, leishmaniasis, Babesia, Acanthamoeba, Balamuthia, and Naegleria in solid organ transplant recipients - guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13546. http://www.ncbi.nlm.nih.gov/pubmed/30900295?tool=bestpractice.com
After completing initial treatment, patients should continue to receive secondary prophylaxis to prevent re-activation of disease for as long as they remain immunocompromised. The optimal duration for prophylaxis after transplant is unknown, and it is sometimes continued for life. Lifelong prophylaxis is recommended for high-risk heart transplant recipients (where the donor is Toxoplasma immunoglobulin [Ig] G positive and the recipient isToxoplasma IgG negative).
Primary options
dapsone: children and adults: consult specialist for guidance on dose
and
pyrimethamine: children and adults: consult specialist for guidance on dose
and
calcium folinate: children and adults: consult specialist for guidance on dose
pyrimethamine + sulfadiazine + calcium folinate
Given to newborns with confirmed or highly suspected congenital disease to prevent or limit damage to the central nervous system and eyes and to prevent death.
Initiate before 2.5 months of life and continue for 1 year.[11]Maldonado YA, Read JS, Committee on Infectious Diseases. Diagnosis, treatment, and prevention of congenital toxoplasmosis in the United States. Pediatrics. 2017 Feb;139(2):e20163860. https://publications.aap.org/pediatrics/article/139/2/e20163860/59988/Diagnosis-Treatment-and-Prevention-of-Congenital [49]Department of Health and Human Services, Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV. Aug 2023 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/pediatric-oi/guidelines-pediatric-oi.pdf [55]McLeod R, Boyer K, Karrison T, et al. Outcome of treatment for congenital toxoplasmosis, 1981-2004: the National Collaborative Chicago-Based, Congenital Toxoplasmosis Study. Clin Infect Dis. 2006 May 15;42(10):1383-94. http://www.ncbi.nlm.nih.gov/pubmed/16619149?tool=bestpractice.com
Benefits include reduced risk of blindness, intellectual disability, seizures, and death.
Risks are side effects from medicines (e.g., bone marrow suppression or hypersensitivity reaction).
Primary options
pyrimethamine: 2 mg/kg orally once daily for 2 days, followed by 1 mg/kg once daily for 2-6 months, then 1 mg/kg three times weekly
and
sulfadiazine: 50 mg/kg orally twice daily
and
calcium folinate: 10 mg orally/intramuscularly with each dose of pyrimethamine
prednisolone
Additional treatment recommended for SOME patients in selected patient group
Given only in the setting of elevated cerebrospinal fluid (CSF) protein (>1 g) or in severe, vision-threatening chorioretinitis, when it is given to prevent loss of vision and blindness, and to reduce the duration of symptomatic disease.[11]Maldonado YA, Read JS, Committee on Infectious Diseases. Diagnosis, treatment, and prevention of congenital toxoplasmosis in the United States. Pediatrics. 2017 Feb;139(2):e20163860. https://publications.aap.org/pediatrics/article/139/2/e20163860/59988/Diagnosis-Treatment-and-Prevention-of-Congenital
Rapidly taper after resolution of elevated CSF protein or after resolution of ocular inflammation.
Primary options
prednisolone: 1 mg/kg/day orally
non-sulfonamide regimen
For patients allergic to or severely intolerant of sulfonamides.
None of these alternative regimens have been adequately studied to warrant formal recommendations, although they are recommended in the guidelines.[49]Department of Health and Human Services, Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV. Aug 2023 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/pediatric-oi/guidelines-pediatric-oi.pdf
Primary options
pyrimethamine: 2 mg/kg orally once daily for 2 days, followed by 1 mg/kg once daily for 2-6 months, then 1 mg/kg three times weekly
and
calcium folinate: 10 mg orally/intramuscularly with each dose of pyrimethamine
and
clindamycin: consult specialist for guidance on dose
prednisolone
Additional treatment recommended for SOME patients in selected patient group
Given only in the setting of elevated cerebrospinal fluid (CSF) protein (>1 g) or in severe, vision-threatening chorioretinitis, when it is given to prevent loss of vision and blindness, and to reduce the duration of symptomatic disease.[11]Maldonado YA, Read JS, Committee on Infectious Diseases. Diagnosis, treatment, and prevention of congenital toxoplasmosis in the United States. Pediatrics. 2017 Feb;139(2):e20163860. https://publications.aap.org/pediatrics/article/139/2/e20163860/59988/Diagnosis-Treatment-and-Prevention-of-Congenital
Rapidly taper after resolution of elevated CSF protein or after resolution of ocular inflammation.
Primary options
prednisolone: 1 mg/kg/day orally
pyrimethamine + sulfadiazine + calcium folinate
For all patients with suspected or confirmed disease. Given to prevent death and organ-specific damage.
Duration of treatment for acute disease is at least 6 weeks, but patients may require a longer course if central nervous system lesions have not resolved.[24]Department of Health and Human Services, Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. May 2024 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf [25]Hoz RM La, Morris MI; Infectious Diseases Community of Practice of the American Society of Transplantation. Tissue and blood protozoa including toxoplasmosis, Chagas disease, leishmaniasis, Babesia, Acanthamoeba, Balamuthia, and Naegleria in solid organ transplant recipients - guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13546. http://www.ncbi.nlm.nih.gov/pubmed/30900295?tool=bestpractice.com
Primary options
pyrimethamine: children: 2 mg/kg (maximum 50 mg/dose) orally once daily for 3 days, followed by 1 mg/kg (maximum 25 mg/dose) once daily; adults (body weight <60 kg): 200 mg orally as a loading dose, followed by 50 mg once daily; adults (body weight ≥60 kg): 200 mg orally as a loading dose, followed by 75 mg once daily
and
sulfadiazine: children: 25-50 mg/kg (maximum 1500 mg/dose) orally four times daily; adults (body weight <60 kg): 1000 mg orally four times daily; adults (body weight ≥60 kg): 1500 mg orally four times daily
and
calcium folinate: children and adults: 10-25 mg orally once daily
More calcium folinateCan increase dose to 50 mg orally once or twice daily in adults.
dexamethasone
Additional treatment recommended for SOME patients in selected patient group
Given only to treat mass effect or associated oedema. Discontinue as soon as clinically feasible.
Primary options
dexamethasone: children: 1-2 mg/kg intravenously initially, followed by 1 to 1.5 mg/kg/day given in divided doses every 4-6 hours until symptoms resolve, then gradually taper; adults: 10 mg intravenously initially, followed by 4 mg every 6 hours until symptoms resolve, then gradually taper
alternative sulfonamide or non-sulfonamide regimen
Treatment is given for at least 6 weeks.
Primary options
pyrimethamine: children: 2 mg/kg (maximum 50 mg/dose) orally once daily for 3 days, followed by 1 mg/kg (maximum 25 mg/dose) once daily; adults (body weight <60 kg): 200 mg orally as a loading dose, followed by 50 mg once daily; adults (body weight ≥60 kg): 200 mg orally as a loading dose, followed by 75 mg once daily
and
clindamycin: children: 5 to 7.5 mg/kg (maximum 600 mg/dose) orally/intravenously every 6 hours; adults: 600 mg orally/intravenously every 6 hours
and
calcium folinate: children and adults: 10-25 mg orally once daily
More calcium folinateCan increase dose to 50 mg orally once or twice daily in adults.
OR
trimethoprim/sulfamethoxazole: adults: 5 mg/kg intravenously/orally twice daily
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim component. Should be used in place of pyrimethamine plus sulfadiazine if pyrimethamine is unavailable or there is a delay in obtaining it.
OR
pyrimethamine: adults (body weight <60 kg): 200 mg orally as a loading dose, followed by 50 mg once daily; adults (body weight ≥60 kg): 200 mg orally as a loading dose, followed by 75 mg once daily
and
atovaquone: adults: 1500 mg orally twice daily
and
calcium folinate: adults: 10-25 mg orally once daily
More calcium folinateCan increase dose to 50 mg orally once or twice daily.
OR
atovaquone: adults: 1500 mg orally twice daily
and
sulfadiazine: adults (body weight <60 kg): 1000 mg orally four times daily; adults (body weight ≥60 kg): 1500 mg orally four times daily
OR
atovaquone: adults: 1500 mg orally twice daily
dexamethasone
Additional treatment recommended for SOME patients in selected patient group
Given only to treat mass effect or associated oedema.
Primary options
dexamethasone: children: 1-2 mg/kg intravenously initially, followed by 1 to 1.5 mg/kg/day given in divided doses every 4-6 hours until symptoms resolve then gradually taper; adults: 10 mg intravenously initially, followed by 4 mg every 6 hours until symptoms resolve then gradually taper
observation and assessment
Most infections in healthy people are mild and self-limiting and do not need treatment; such patients should be observed.
pyrimethamine + sulfadiazine + calcium folinate + prednisolone
Additional treatment recommended for SOME patients in selected patient group
Patients with chorioretinitis who are immunocompetent may require treatment to prevent loss of vision and to reduce the duration of symptomatic disease. Treatment for both congenital and acquired ocular disease is controversial and depends on expert evaluation of the clinical findings. It should be undertaken only in conjunction with an ophthalmologist.
One systematic review concluded that antibiotic treatment probably reduces the risk of recurrent toxoplasmic chorioretinitis, but there was a lack of evidence that antibiotics resulted in better visual outcomes, and there were no data evaluating the effects of adjunctive corticosteroids.[57]Pradhan E, Bhandari S, Gilbert RE, et al. Antibiotics versus no treatment for toxoplasma retinochoroiditis. Cochrane Database Syst Rev. 2016 May 20;(5):CD002218. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002218.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/27198629?tool=bestpractice.com [58]Jasper S, Vedula SS, John SS, et al. Corticosteroids as adjuvant therapy for ocular toxoplasmosis. Cochrane Database Syst Rev. 2017 Jan 26;(1):CD007417. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369355 http://www.ncbi.nlm.nih.gov/pubmed/28125765?tool=bestpractice.com Despite a lack of evidence to support routine antibiotic treatment, treatment is warranted for severe or persistent lesions involving the macula or optic nerve, for large retinal lesions with severe inflammation, and for any lesion in a person who is immunocompromised.[57]Pradhan E, Bhandari S, Gilbert RE, et al. Antibiotics versus no treatment for toxoplasma retinochoroiditis. Cochrane Database Syst Rev. 2016 May 20;(5):CD002218. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002218.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/27198629?tool=bestpractice.com [58]Jasper S, Vedula SS, John SS, et al. Corticosteroids as adjuvant therapy for ocular toxoplasmosis. Cochrane Database Syst Rev. 2017 Jan 26;(1):CD007417. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369355 http://www.ncbi.nlm.nih.gov/pubmed/28125765?tool=bestpractice.com [59]Stanford MR, See SE, Jones LV, et al. Antibiotics for toxoplasmic retinochoroiditis: an evidence-based systematic review. Ophthalmology. 2003 May;110(5):926-31;quiz 931-2. http://www.ncbi.nlm.nih.gov/pubmed/12750091?tool=bestpractice.com
Standard treatment is with pyrimethamine, sulfadiazine, calcium folinate, and prednisolone. Treatment should be continued for 1 to 2 weeks after signs and symptoms resolve.
Other treatment regimens, such as those containing clindamycin, trimethoprim/sulfamethoxazole or azithromycin, have been used to variable effect, but there is insufficient evidence to recommend these treatments.[62]Soheilian M, Sadoughi MM, Ghajarnia M, et al. Prospective randomized trial of trimethoprim/sulfamethoxazole versus pyrimethamine and sulfadiazine in the treatment of ocular toxoplasmosis. Ophthalmology. 2005 Nov;112(11):1876-82. http://www.ncbi.nlm.nih.gov/pubmed/16171866?tool=bestpractice.com [63]Sobrin L, Kump LI, Foster CS. Intravitreal clindamycin for toxoplasmic retinochoroiditis. Retina. 2007 Sep;27(7):952-7. http://www.ncbi.nlm.nih.gov/pubmed/17891023?tool=bestpractice.com [64]Bosch-Driessen LH, Verbraak FD, Suttorp-Schulten MS, et al. A prospective, randomized trial of pyrimethamine and azithromycin vs pyrimethamine and sulfadiazine for the treatment of ocular toxoplasmosis. Am J Ophthalmol. 2002 Jul;134(1):34-40. http://www.ncbi.nlm.nih.gov/pubmed/12095805?tool=bestpractice.com
Primary options
pyrimethamine: children: 2 mg/kg (maximum 50 mg/dose) orally once daily for 3 days, followed by 1 mg/kg (maximum 25 mg/dose) once daily; adults (body weight <60 kg): 200 mg orally as a loading dose, followed by 50 mg once daily; adults (body weight ≥60 kg): 200 mg orally as a loading dose, followed by 75 mg once daily
and
sulfadiazine: children: 25-50 mg/kg (maximum 1500 mg/dose) orally four times daily; adults (body weight <60 kg): 1000 mg orally four times daily; adults (body weight ≥60 kg): 1500 mg orally four times daily
and
calcium folinate: children and adults: 10-25 mg orally once daily
More calcium folinateCan increase dose to 50 mg orally once or twice daily in adults.
and
prednisolone: children and adults: 1 mg/kg/day orally, maximum 40 mg/day, continue until signs of active, vision-threatening chorioretinitis subside, then taper and discontinue
spiramycin OR pyrimethamine + sulfadiazine + calcium folinate
Spiramycin can be given if maternal infection occurs before 18 weeks' gestation and is continued throughout pregnancy if there is no evidence of transmission of infection to the fetus.[11]Maldonado YA, Read JS, Committee on Infectious Diseases. Diagnosis, treatment, and prevention of congenital toxoplasmosis in the United States. Pediatrics. 2017 Feb;139(2):e20163860. https://publications.aap.org/pediatrics/article/139/2/e20163860/59988/Diagnosis-Treatment-and-Prevention-of-Congenital Although marketed worldwide, it is not currently licensed for toxoplasmosis in the UK where it can be obtained on named-patient use.
If maternal infection occurs after 18 weeks gestation, or fetal transmission has been documented on amniotic fluid PCR at ≥18 weeks gestation, pyrimethamine/sulfadiazine/calcium folinate should be given.[11]Maldonado YA, Read JS, Committee on Infectious Diseases. Diagnosis, treatment, and prevention of congenital toxoplasmosis in the United States. Pediatrics. 2017 Feb;139(2):e20163860. https://publications.aap.org/pediatrics/article/139/2/e20163860/59988/Diagnosis-Treatment-and-Prevention-of-Congenital
Ultrasound follow-up should include examination of the fetus every 4 weeks, with a focus on brain, eye, and growth assessment.[11]Maldonado YA, Read JS, Committee on Infectious Diseases. Diagnosis, treatment, and prevention of congenital toxoplasmosis in the United States. Pediatrics. 2017 Feb;139(2):e20163860. https://publications.aap.org/pediatrics/article/139/2/e20163860/59988/Diagnosis-Treatment-and-Prevention-of-Congenital [53]Khalil A, Sotiriadis A, Chaoui R, et al. ISUOG practice guidelines: role of ultrasound in congenital infection. Ultrasound Obstet Gynecol. 2020 Jul;56(1):128-51. https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.21991 http://www.ncbi.nlm.nih.gov/pubmed/32400006?tool=bestpractice.com
Primary options
<18 weeks’ gestation
spiramycin: 1 g orally every 8 hours
OR
≥18 weeks’ gestation
pyrimethamine: 50 mg orally twice daily for 2 days, followed by 50 mg once daily
and
sulfadiazine: 75 mg/kg orally as a single dose, followed by 50 mg/kg twice daily, maximum 4000 mg/day
and
calcium folinate: 10-20 mg orally once daily
pyrimethamine + sulfadiazine + calcium folinate
Given after the initial course of treatment to all patients to prevent relapse of symptomatic disease.
However, it may be stopped in patients with HIV on antiretroviral therapy who have CD4+ T lymphocytes >200 cells/microlitre for 6 or more months, or in transplant recipients on no immunosuppressive medications.[24]Department of Health and Human Services, Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. May 2024 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf
Primary options
pyrimethamine: children: 1 mg/kg (or 15 mg/square metre of body surface area) orally once daily, maximum 25 mg/day; adults: 25-50 mg orally once daily
and
sulfadiazine: children: 42.5 to 60 mg/kg orally twice daily, maximum 4000 mg/day; adults: 2000-4000 mg/day orally given in 2-4 divided doses
and
calcium folinate: children: 5 mg orally every three days; adults: 10-25 mg orally once daily
alternative maintenance regimen
Alternative regimens given after initial course of treatment to all patients to prevent relapse of symptomatic disease.[24]Department of Health and Human Services, Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. May 2024 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf
However, it may be stopped in patients with HIV on antiretroviral therapy who have CD4+ T lymphocytes >200 cells/microlitre for 6 or more months, or in transplant recipients on no immunosuppressive medicines.[24]Department of Health and Human Services, Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. May 2024 [internet publication]. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf
Primary options
pyrimethamine: children: 1 mg/kg (or 15 mg/square metre of body surface area) orally once daily, maximum 25 mg/day; adults: 25-50 mg orally once daily
and
clindamycin: children: 7-10 mg/kg orally three times daily; adults: 600 mg orally three times daily
and
calcium folinate: children: 5 mg orally every three days; adults: 10-25 mg orally once daily
OR
trimethoprim/sulfamethoxazole: children: 150 mg/square metre of body surface area orally once daily; adults: 160 mg orally once or twice daily
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim component.
OR
atovaquone: children 4-24 months of age: 45 mg/kg orally once daily; adults: 750-1500 mg orally twice daily
and
pyrimethamine: children 4-24 months of age: 1 mg/kg (or 15 mg/square metre of body surface area) orally once daily, maximum 25 mg/day; adults: 25 mg orally once daily
and
calcium folinate: children 4-24 months of age: 5 mg orally every three days; adults: 10 mg orally once daily
OR
atovaquone: children 1-3 months of age and >24 months of age: 30 mg/kg orally once daily; children 4-24 months of age: 45 mg/kg orally once daily; adults: 750-1500 mg orally twice daily
OR
atovaquone: adults: 750-1500 mg orally twice daily
and
sulfadiazine: adults: 2000-4000 mg/day orally given in 2-4 divided doses
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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