• 1

    Rossignol JF, Cavier R, 1975. New derivative of 2-benzamido-5-nitrothiols. Chem Abs 83 :28216.

  • 2

    Rossignol JF, Maisonneuve H, 1984. Nitazoxanide in the treatment of Taenia saginata and Hymenolepis nana infections. Am J Trop Med Hyg 33 :511–512.

    • Search Google Scholar
    • Export Citation
  • 3

    Rossignol JF, Abaza H, Friedman H, 1998. Successful treatment of fasciolosis with nitazoxanide. Trans R Soc Trop Med Hyg 92 :103–104.

  • 4

    Doumbo O, Rossignol JF, Pichard E, Traore HA, Dembele M, Diakite M, Traore F, Diallo DA, 1997. Nitazoxanide in the treatment of cryptosporidial diarrhea and other intestinal parasitic infections associated with acquired immunodeficiency syndrome in tropical Africa. Am J Trop Med Hyg 56 :637–639.

    • Search Google Scholar
    • Export Citation
  • 5

    Romero CR, Robert GL, Muñoz GMR, Geyne CA, 1997. Nitazoxanide for the treatment of intestinal protozoan and helminthic infections in Mexico. Trans R Soc Trop Med Hyg 91 :701–703.

    • Search Google Scholar
    • Export Citation
  • 6

    Abaza H, El-Zayali A, Kabil SM, Rizk H, 1998. Nitazoxanide in the treatment of patients with intestinal protozoan and helminthic infections: a report on 546 patients in Egypt. Curr Ther Res 59 :116–121.

    • Search Google Scholar
    • Export Citation
  • 7

    Garcia L, Bullock-Iacullo S, Fritsche T, Healy G, McAuley J, Neimeister R, Palmer J, Wilson M, Wong J, 1997. Procedures for Recovery and Identification of Parasites from the Intestinal Tract. Approved Guideline. Wayne, PA: National Committee for Clinical and Laboratory Standards, 17: 8–10 and 25–27.

  • 8

    Biagi F, Portilla J, 1957. Comparison of methods of examining stools for parasites. Am J Trop Med Hyg 6 :906–911.

  • 9

    Henriksen SA, Pohlenz JFL, 1981. Staining cryptosporidia by a modified Ziehl-Nielsen technique. Acta Vet Scand 22 :594–596.

  • 10

    Ortiz J, Ayoub A, Gargala G, Chegne N, Favennec L, 2001. Randomized clinical study of nitazoxanide compared to metronidazole in the treatment of symptomatic giardiasis in children from northern Peru. Aliment Pharmacol Ther 15 :1409–1415.

    • Search Google Scholar
    • Export Citation

 

 

 

 

EPIDEMIOLOGY AND CONTROL OF INTESTINAL PARASITES WITH NITAZOXANIDE IN CHILDREN IN MEXICO

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  • 1 Unidad de Medicina Familiar 91, Instituto Mexicano del Seguro Social, Estado de Mexico, México; Departamento de Ciencias Químicas, Facultad de Estudios Superiores Cuautitlán, Universidad Nacional Autónoma de México, Estado de México, México; Laboratorio de Parasitología y Micología, Hospital Infantil de México Federico Gómez, Secretaría de Salubridad y Asistencia, México, DF, México

The purpose of this study was to evaluate the efficacy and the tolerance of nitazoxanide in children as a single broad-spectrum antiparasitic agent in the treatment of mixed parasite infections with both intestinal protozoa and helminths. Two hundred seventy-two children (age range = 2–14 years) participated in this study. We systematically surveyed every household head using questionnaires designed to obtain information about household socioeconomic status and hygiene. Parasitic infections were confirmed by three stool examinations using direct smear, Ferreira concentration, and cold acid-fast Kinyoun staining methods. One hundred twenty-one (44%) children tested positive for protozoa such as Giardia lamblia (18%), Entamoeba histolytica/E. dispar (10%), Blastocystis hominis (7%), Cryptosporidium parvum (4%), and Cyclospora cayetanensis (3%), and helminths such as Hymenolepis nana (10%), Trichuris trichiura (6%), and Ascaris lumbricoides (6%). There were also two cases of infection with Enterobius vermicularis. After a complete physical examination was performed, 121 patients received treatment with nitazoxanide. Overall, 84% of the protozoa and 95% of the helminths were completely eliminated from the patients. Nitazoxanide was very well tolerated, with no serious adverse effects reported.

Nitazoxanide is a new 5-nitrothiazole derivative with broad spectrum anthelminthic and antiprotozoan activity.1 It has been shown to be effective against infections with Ascaris lumbricoides, Trichuris trichiura, Taenia saginata, Hymenolepis nana, and Fasciola hepatica, as well as infections with common protozoa such as Cryptosporidium parvum, Blastocystis hominis, Entamoeba histolytica, Giardia lamblia, and Isospora belli.2–4 This drug is also well tolerated, with only minor clinical side effects such as abdominal pain (4% of patients) being observed.5,6

The purpose of the present study was to evaluate the efficacy and the tolerance of nitazoxanide in children as a single broad spectrum antiparasitic agent in the treatment of mixed parasite infections with both intestinal protozoa and helminths. Our study was conducted to determine the prevalence and nature of intestinal parasitic infections in children from Coacalco de Berriozabal (population = 240,000), which is located northeast of Mexico City.

Two hundred seventy-two children (age range = 2–14 years) from 85 families participated in the study. Stool samples were collected from March 1997 to January 1998. Cases were defined as boys and girls with stool samples positive for pathogen parasites by direct smear, Ferreira concentration (1:10), and cold acid-fast Kinyoun staining methods.7–9 A physical examination was performed and medication was administered at the Family Medical Unit 91 in Estado de Mexico by a general physician under the supervision of the principal investigator and the parents of the children. Ten days after the treatment was concluded, children with parasitic infections were questioned and a stool sample was collected from each child on three consecutive days for parasitologic examination. One hundred eighty-four (68%) of the cases were between 6 and 12 years old. The case population had a greater proportion of boys (54%).

One hundred twenty-one (44%) children tested positive for protozoa such as Giardia lamblia (18%), Entamoeba histolytica/E. dispar (10%), Blastocystis hominis (7%), Cryptosporidium parvum (4%), and Cyclospora cayetanensis (3%), and helminths such as Hymenolepis nana (10%), Trichuris trichiura (6%), and Ascaris lumbricoides (6%). There were also two cases of infection with Enterobius vermicularis. Of the 121 parasite-positive patients, 84 (69%) had a single parasitic infection, 37 (31%) had mixed infections involving two or more parasites (Table 1), and one had infections with eight different organisms.

Results of the physical examinations showed that 103 (85%) children had abdominal pain, 76 (63%) had meteorism, 67 (55%) had flatulence, 52 (43%) had anorexia, 52 (43%) had irritability, 44 (36%) had diarrhea, 43 (35%) had nausea, 42 (35%) had anal itching, 42 (35%) had hyporexia, and 38 (31%) had asthenia as clinical manifestations before treatment. Clinical manifestations were less common in children less than six years old and more common in children 6–12 years old.

The efficacy rate following treatment with nitazoxanide was determined as the percentage of children with three fecal samples negative by the three methods used (87.6%, 106 of 121). This criterion is used for all intestinal parasites in pediatric hospitals in Mexico.

Nitazoxanide was highly effective against either single or mixed infections with C. parvum, T. trichiura, and A. lumbricoides (Table 2). In 28 patients infected with H. nana, cures rates of 84% were observed following three treatments.

The parasitologic response rates observed for G. lamblia were similar to those previously reported.5,10 Blastocystis hominis and E. histolytica were found in three patients after first treatment. However, nitazoxanide has been reported to be highly effective against these parasites.5

An evaluation of the intensity of helminth infections based on egg counts showed that most of the cases were light infections. Only three of 16 cases of A. lumbricoides and five of 28 cases of infection with H. nana were moderate infections. All cases of infection with T. trichiura and A. lumbricoides showed the presence of eggs after treatment. Cases of infection with H. nana that were not cured after treatment were considered moderate infections; however, eggs counts were significantly reduced.

Despite resistance to nitazoxanide that has been observed in some organisms (e.g., G. lamblia and C. cayetanensis), this drug appears to show good efficacy in the treatment of intestinal parasitic infections, with little variation in parasite sensitivity. Thus, it could be used during massive chemotherapy campaigns. These results are consistent with those previously reported, and both show that nitazoxanide is highly effective and well tolerated (only 3% of the patients reported minor clinical side effects) in treating infections with helminths and protozoa.

Table 1

Parasite association in 121 children before treatment

Number of children (%)
Single84 (69)
Multiple37 (31)
Total121
Protozoa + protozoa13 (11)
Helminth + helminth5 (4)
Protozoa + helminth19 (16)
Total37
Table 2

Efficacy rates (%) of treatment with nitazoxanide

ParasitesFirst treatmentSecond treatmentThird treatment
Pathogenic protozoa
    Giardia lamblia697981
    Entamoeba histolytica96100
    Blastocystic hominis97100
    Cryptosporidium parvum100
    Cyclospora cayetanensis717587
Helminths
    Hymenolepis nana808084
    Trichuris trichiura100
    Ascaris lumbricoides100
    Enterobius vermicularis100

Authors’ addresses: Elvia Díaz, Unidad de Medicina Familiar 91, Instituto Mexicano del Seguro Social, Av. López Portillo s/n, Coacalco de Berriozabal, CP 55700 Estado de México, México. Jaime Mondragón, Departamento de Ciencias Químicas, Facultad de Estudios Superiores Cuautitlán, Universidad Nacional Autónoma de México, Campo 1, Av. 1° de Mayo s/n, Cuautitlán Izcalli, CP 54740 Estado de México, México. Enrique Ramírez and Rosamaria Bernal, Laboratorio de Parasitología y Micología, Hospital Infantil de México Federico Gómez, Secretaría de Salubridad y Asistencia, Dr. Márquez 162, Col. Doctores CP 06720 México, DF, México.

Acknowledgments: We thank R. Miranda and A. Romero for critical review of the manuscript; Laboratorios Columbia S.A. de C.V., México, for providing the nitazoxanide; T. Aguirre for invaluable assistance in the field; and A. Gámez, the late G. Hernández, and A. Morales for their outstanding technical assistance.

REFERENCES

  • 1

    Rossignol JF, Cavier R, 1975. New derivative of 2-benzamido-5-nitrothiols. Chem Abs 83 :28216.

  • 2

    Rossignol JF, Maisonneuve H, 1984. Nitazoxanide in the treatment of Taenia saginata and Hymenolepis nana infections. Am J Trop Med Hyg 33 :511–512.

    • Search Google Scholar
    • Export Citation
  • 3

    Rossignol JF, Abaza H, Friedman H, 1998. Successful treatment of fasciolosis with nitazoxanide. Trans R Soc Trop Med Hyg 92 :103–104.

  • 4

    Doumbo O, Rossignol JF, Pichard E, Traore HA, Dembele M, Diakite M, Traore F, Diallo DA, 1997. Nitazoxanide in the treatment of cryptosporidial diarrhea and other intestinal parasitic infections associated with acquired immunodeficiency syndrome in tropical Africa. Am J Trop Med Hyg 56 :637–639.

    • Search Google Scholar
    • Export Citation
  • 5

    Romero CR, Robert GL, Muñoz GMR, Geyne CA, 1997. Nitazoxanide for the treatment of intestinal protozoan and helminthic infections in Mexico. Trans R Soc Trop Med Hyg 91 :701–703.

    • Search Google Scholar
    • Export Citation
  • 6

    Abaza H, El-Zayali A, Kabil SM, Rizk H, 1998. Nitazoxanide in the treatment of patients with intestinal protozoan and helminthic infections: a report on 546 patients in Egypt. Curr Ther Res 59 :116–121.

    • Search Google Scholar
    • Export Citation
  • 7

    Garcia L, Bullock-Iacullo S, Fritsche T, Healy G, McAuley J, Neimeister R, Palmer J, Wilson M, Wong J, 1997. Procedures for Recovery and Identification of Parasites from the Intestinal Tract. Approved Guideline. Wayne, PA: National Committee for Clinical and Laboratory Standards, 17: 8–10 and 25–27.

  • 8

    Biagi F, Portilla J, 1957. Comparison of methods of examining stools for parasites. Am J Trop Med Hyg 6 :906–911.

  • 9

    Henriksen SA, Pohlenz JFL, 1981. Staining cryptosporidia by a modified Ziehl-Nielsen technique. Acta Vet Scand 22 :594–596.

  • 10

    Ortiz J, Ayoub A, Gargala G, Chegne N, Favennec L, 2001. Randomized clinical study of nitazoxanide compared to metronidazole in the treatment of symptomatic giardiasis in children from northern Peru. Aliment Pharmacol Ther 15 :1409–1415.

    • Search Google Scholar
    • Export Citation

Author Notes

Reprint requests: Rosamaría Bernal, Laboratorio de Parasitología y Micología, Hospital Infantil de México Federico Gómez, Secretaría de Salubridad y Asistencia, Dr. Márquez 162, Col. Doctores CP 06720 México, DF México. E-mail: rbernal@bolivar.usb.mx
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