Babesiosis in Highly Immunocompromised Patients After First-Line Treatment Failure
This protocol addresses babesiosis management when first-line therapy fails to clear parasitemia in patients with significant immunosuppression — a population at heightened risk for refractory and relapsing infection.
Patient Population
Highly immunocompromised patients — including those receiving rituximab for B cell lymphoma or an autoimmune disorder, on immunosuppressive regimens for solid organ or bone marrow transplantation or malignancy, patients with malignancy and asplenia, or those with HIV infection and low CD4 T cell counts (AIDS).
First-Line Failure Condition
Initial therapy — a 6-week course of atovaquone plus azithromycin (or clindamycin plus quinine), including a step-down phase — did not achieve the required endpoint:
Babesia parasites remained detectable on peripheral blood smear during the 2 final weeks of treatment. This protocol is indicated when that goal is not met.
Refractory Management — Partial Overview
When parasitemia persists despite first-line therapy, management involves switching to one of several alternative atovaquone-based combination regimens — with the specific combination determined by clinical factors detailed in the full protocol.
Complete regimen selection, sequencing criteria, and clinical decision logic are available in the full protocol below.
References
DOI: 10.1093/cid/ciab275
They include those who (i) have received or are receiving rituximab for B cell lymphoma or an autoimmune disorder, (ii) are receiving other immunosuppressive regimens for solid organ or bone marrow transplantation or malignancy, (iii) have malignancy and are asplenic, or (iv) have HIV infection with low CD4 T cell counts (AIDS).
If infection relapses, consider one of the regimens listed in Table 3.
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