Correspondence

The Treatment of Babesiosis

N Engl J Med 2001; 344:773-774March 8, 2001

Article

To the Editor:

We concur with Krause et al. (Nov. 16 issue)1 that the combination of azithromycin and atovaquone is effective for the treatment of babesiosis. We have been using atovaquone and azithromycin as an alternative treatment for babesiosis since 1993. Our studies of babesiosis in hamsters showed that atovaquone and azithromycin are effective agents for the treatment of babesiosis.2,3

We have used a combination of azithromycin at a dose of 12 mg per kilogram of body weight per day and atovaquone at a dose of 40 mg per kilogram per day in neonates with success and without toxic effects.4 We have also used a combination of 500 to 1000 mg of azithromycin daily and 750 mg of atovaquone twice daily with success in immunocompromised patients with human immunodeficiency virus infection, elderly patients, and a patient with IgM myeloma. More recently, we have used 600 mg of azithromycin per day in adults because of the availability of a tablet at this dose. An important difference between our therapeutic regimen and that of Krause et al. is thus the dose of azithromycin. In our experience, the higher dose of azithromycin (600 mg per day) leads to earlier resolution of fever and rapid decline and clearance of parasites from the blood. The use of the higher dose of azithromycin was based on data on the efficacy of azithromycin monotherapy in hamsters.2 It is important to emphasize that atovaquone should not be used as monotherapy because experimental evidence shows that, as with drugs for malaria, there is rapid emergence of resistance to drugs used to treat babesiosis.3

Louis M. Weiss, M.D., M.P.H.
Murray Wittner, M.D., Ph.D.
Herbert B. Tanowitz, M.D.
Albert Einstein College of Medicine of Yeshiva University, Bronx, NY 10461

4 References

1. 1

   Krause PJ, Lepore T, Sikand VK, et al. Atovaqone and azithromycin for the treatment of babesiosis. N Engl J Med 2000;343:1454-1458
   Full Text | Web of Science | Medline

2. 2

   Weiss LM, Wittner M, Wasserman S, Oz HS, Retsema J, Tanowitz HB. Efficacy of azithromycin for treating Babesia microti infection in the hamster model. J Infect Dis 1993;168:1289-1292
   CrossRef | Web of Science | Medline

3. 3

   Wittner M, Lederman J, Tanowitz HB, Rosenbaum GS, Weiss LM. Atovaquone in the treatment of Babesia microti infections in hamsters. Am J Trop Med Hyg 1996;55:219-222
   Web of Science | Medline

4. 4

   Dobroszycki J, Herwaldt BL, Boctor F, et al. A cluster of transfusion-associated babesiosis cases traced to a single asymptomatic donor. JAMA 1999;281:927-930
   CrossRef | Web of Science | Medline

To the Editor:

Although the study by Krause et al. lacked the power to detect a statistically significant difference, the combination of atovaquone and azithromycin tended to be more effective than the combination of quinine and clindamycin with respect to both the resolution of the symptoms and the duration of Babesia microti infection. Treatment with atovaquone and azithromycin was also significantly better tolerated than quinine and clindamycin.

However, a serious limitation is the high cost of the atovaquone-and-azithromycin regimen. Since most of the adverse drug reactions in the clindamycin-and-quinine group were due to quinine rather than to clindamycin, the rationale for replacing quinine with atovaquone is clear. But why replace clindamycin with azithromycin? Both antimicrobials interact with the large ribosomal subunit, and clindamycin is considerably cheaper than azithromycin. Studies evaluating a regimen of atovaquone and clindamycin in the treatment of babesiosis would be of interest.

Stéphane Ranque, M.D.
Université de la Méditerranée, F-13385 Marseilles, France

Citing Articles (6)

Citing Articles

1. 1

   B. A. Cunha, S. Nausheen, D. Szalda. (2007) Pulmonary complications of babesiosis: case report and literature review. European Journal of Clinical Microbiology & Infectious Diseases 26:7, 505-508
   CrossRef

2. 2

   Cabot, Richard C.Harris, Nancy Lee, Shepard, Jo-Anne O., Rosenberg, Eric S., Cort, Alice M., Ebeling, Sally H.Peters, Christine C., Stowell, Christopher P., Gelfand, Jeffrey A., Shepard, Jo-Anne O., Kratz, Alexander, . (2007) Case 17-2007. New England Journal of Medicine 356:22, 2313-2319
   Full Text

3. 3

   Gary P. Wormser, Raymond J. Dattwyler, Eugene D. Shapiro, John J. Halperin, Allen C. Steere, Mark S. Klempner, Peter J. Krause, Johan S. Bakken, Franc Strle, Gerold Stanek, Linda Bockenstedt, Durland Fish, J. Stephen Dumler, Robert B. Nadelman. (2006) The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases 43:9, 1089-1134
   CrossRef

4. 4

   Henri J. Vial, A. Gorenflot. (2006) Chemotherapy against babesiosis. Veterinary Parasitology 138:1-2, 147-160
   CrossRef

5. 5

   Louis M Weiss. (2002) Babesiosis in humans: a treatment review. Expert Opinion on Pharmacotherapy 3:8, 1109-1115
   CrossRef

6. 6

   Cynthia J. Mollen, Louis M. Bell. (2002) Tick-Borne Illnesses in the United States. Pediatric Case Reviews 2:1, 14-25
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