Emerging treatments
Pentamidine plus trimethoprim/sulfamethoxazole
This combination is moderately effective in improving symptoms and clearing parasitemia in Babesia divergens infection, but adverse reactions to intravenous pentamidine limit its use. Furthermore, pentamidine's effect is too slow for its use against B divergens-like parasites.[38]
Azithromycin plus quinine
This combination was used successfully in 2 Taiwanese patients who had not improved after clindamycin plus quinine. Both patients were cleared of parasitemia with a course of azithromycin plus quinine.[39][40]
Clindamycin plus doxycycline plus azithromycin
Use of this combination has been published as a case report.[41] An immunocompromised patient with HIV infection presented with prolonged (for months) fever of unknown origin, and was subsequently found to have babesiosis. The infection did not respond to clindamycin plus quinine, although treatment was complicated by addition of antiretrovirals and episodic treatment interruptions. The infection was later controlled, but not cured, with clindamycin, doxycycline, and high-dose azithromycin.
Atovaquone/proguanil
Use of atorvaquone/proguanil has been published as a case report of a patient with AIDS who failed to respond to azithromycin plus atovaquone or clindamycin plus quinine, but who then responded to a 5-drug regimen of atovaquone/proguanil, azithromycin, clindamycin, and quinine for 3 weeks, followed by atovaquone/proguanil alone for 60 days.[42]
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