Ability of azithromycin in combination with quinine for the elimination of babesial infection in humans

A Divergent Synthesis of Numerous Pyrroloiminoquinone Alkaloids Identifies Promising Antiprotozoal Agents

On the basis of a streamlined route to the pyrroloiminoquinone (PIQ) core, we made 16 natural products spread across four classes of biosynthetically related alkaloid natural products, and multiple structural analogs, all in ≤8 steps longest linear sequence (LLS). The strategy features a Larock indole synthesis as the key operation in a five-step synthesis of a key methoxy-PIQ intermediate. Critically, this compound was readily diverged via selective methylation of either (or both) of the imine-like or pyrrole nitrogens, which then permitted further divergence by either O-demethylation to o-quinone natural products or displacement of the methoxy group with a range of amine nucleophiles. Based on a single, early report of their potential utility against the malaria parasite, we assayed these compounds against several strains of Plasmodium falciparum, as well as two species of the related protozoan parasite Babesia. In combination with evaluations of their human cytotoxicity, we identified several compounds with potent (low-nM IC50) antimalarial and antibabesial activities that are much less toxic toward mammalian cells and are therefore promising lead compounds for antiprotozoal drug discovery.

Optimization of an Evaluation Method for Anti-Babesia microti Drug Efficacy

Babesiosis is an emerging zoonotic disease that is typically caused by Babesia microti infection. Clinical treatment of B. microti infection is challenging; hence, it is crucial to find new effective drugs. The current laboratory screening methods for anti-B. microti drugs are not optimized. We conducted drug-suppressive and drug-therapeutic tests to investigate whether use of an immunosuppressant and the target gene-based qPCR are helpful to reduce the number of animals affected and to improve parasite detection in an immunocompetent mouse model. These results were verified by subpassage test. In the drug-suppressive test, no B. microti were observed after immunosuppressant administration or in subpassage mice in the 100 mg/kg robenidine hydrochloride (ROBH) group. The opposite results were observed in the control, 50 mg/kg ROBH, atovaquone (ATO) + azithromycin (AZM), and proguanil hydrochloride (PGH) groups. Significant differences were observed in the EIR and target gene relative values (both P < 0.001) between the control group and any ROBH groups. In the drug-therapeutic test, recrudescence occurred in the 50 mg/kg ROBH, ATO+AZM, and control groups. This was not observed in the 100 mg/kg ROBH group after immunosuppressant administration. Similar findings were observed in the subpassage test. This suggests that a 4-day anti-B. microti drug-suppressive test can be used in preliminary drug screening. Potentially effective drugs can be verified by immunosuppressant test in subsequent drug-therapeutic tests. Thus, a laboratory evaluation method of anti-B. microti drug efficacy was optimized, which is highly accurate and requires a short drug screening time.

First zootiological survey of hard ticks (Acari: Ixodidae) infesting dogs in northern Taiwan

Hard ticks infesting canine hosts were determined for the first time in northern Taiwan. Between May 2010 and April 2011, a total of 9467 ticks were collected from 2025 dogs. They were identified based on pictorial keys of their morphological characteristics. These ticks belong to three genus and six species: Rhipicephalus sanguineus, R. haemaphysaloides, Haemaphysalis hystricis, H. lagrangei, H. formosensis and Ixodes ovatus. Rhipicephalus sanguineus was the most dominant species (92.5%), followed by H. hystricis (4.6%), R. haemaphysaloides (2.3%), I. ovatus (0.54%), H. lagrangei (0.04%) and H. formosensis (0.01%). The overall density was 4.7 ticks per dog (ranging from 1.8 to 20.8) and the highest seasonal prevalence was observed in September with an average density of 8.2 ticks per dog. Our results not only provide the first survey of hard ticks infesting dogs in northern Taiwan, but also highlight the possible impact of these tick species on human health.

Radical cure of experimental babesiosis in immunodeficient mice using a combination of an endochin-like quinolone and atovaquone

Human babesiosis is a tick-borne multisystem disease caused by Babesia species of the apicomplexan phylum. Most clinical cases and fatalities of babesiosis are caused by Babesia microti Current treatment for human babesiosis consists of two drug combinations, atovaquone + azithromycin or quinine + clindamycin. These treatments are associated with adverse side effects and a significant rate of drug failure. Here, we provide evidence for radical cure of experimental babesiosis in immunodeficient mice using a combination of an endochin-like quinolone (ELQ) prodrug and atovaquone. In vivo efficacy studies in mice using ELQ-271, ELQ-316, and the ELQ-316 prodrug, ELQ-334, demonstrated excellent growth inhibitory activity against the parasite, with potency equal to that of orally administered atovaquone at 10 mg/kg. Analysis of recrudescent parasites after ELQ or atovaquone monotherapy identified genetic substitutions in the Qi or Qo sites, respectively, of the cytochrome bc1 complex. Impressively, a combination of ELQ-334 and atovaquone, at doses as low as 5.0 mg/kg each, resulted in complete clearance of the parasite with no recrudescence up to 122 d after discontinuation of therapy. These results will set the stage for future clinical evaluation of ELQ and atovaquone combination therapy for treatment of human babesiosis.

Diagnosis and management of human babesiosis

Babesiosis is a protozoan parasitic infection affecting humans and animals. These infections are commonly transmitted by various species of Ixodes ticks depending upon the geographical location. They can also be transmitted by packed cell transfusion and transplacental route from mother to child. Various species have been reported to cause human infections, of which Babesia microti is the most common species reported globally. Usually, Babesia infections are asymptomatic or mild, but can be severe/life-threatening in immunosuppressed or splenectomized individuals. A high index of clinical suspicion in residents of endemic areas or individuals who had a recent travel history to such areas, with laboratory confirmation can guide an early institution of appropriate antimicrobial therapy, thereby preventing complications and death.

The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis were prepared by an expert panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 31[Suppl 1]:1-14). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. For each of these Ixodes tickborne infections, information is provided about prevention, epidemiology, clinical manifestations, diagnosis, and treatment. Tables list the doses and durations of antimicrobial therapy recommended for treatment and prevention of Lyme disease and provide a partial list of therapies to be avoided. A definition of post-Lyme disease syndrome is proposed.

Babesiosis diagnosis and treatment

Human babesiosis due to Babesia microti is an emerging malaria-like infection that is endemic in parts of the northeastern and northcentral United States. The clinical manifestations of babesiosis range from subclinical illness to fulminant disease resulting in death. Prompt and accurate diagnosis is difficult because the signs and symptoms are non-specific. A CBC is a useful screening test since anemia and thrombocytopenia are commonly observed and parasites may be visualized on blood smear. Conclusive diagnosis of this disease generally depends upon microscopic examination of thin blood smears. Babesia frequently are overlooked, however, because parasitemia tends to be sparse, often infecting fewer than 1% of erythrocytes early in the course of the illness. Identification of amplifiable babesial DNA by polymerase chain reaction (PCR) has comparable sensitivity and specificity to microscopic analysis of thin blood smear for detection of babesia in blood. Serologic testing provides useful supplementary evidence of infection because a robust antibody response characterizes human babesial infection, even at the time that parasitemia first becomes detectable. The currently recommended therapy for babesiosis is a 7-10-day course of clindamycin (600 mg every 6 h) and quinine (650 mg every 8 h). Recently, azithromycin (500-600 mg on day 1, and 250-600 mg on subsequent days) and atovaquone (750 mg every 12 h) was found to be equally effective in treating adults experiencing babesiosis. This combination also was associated with fewer adverse reactions than clindamycin and quinine. Exchange transfusion is a potentially life-saving therapy for patients suffering from severe disease with high parasitemia (>5%), significant hemolysis, or renal or pulmonary compromise. Babesiosis may be prevented by avoiding areas such as tall grass and brush where ticks, deer, and mice are known to thrive.

Babesiosis in humans: a treatment review

Human infections with Babesia species, in particular Babesia microti, are tick-borne illnesses that are being recognised with increased frequency. Coinfection with ehrlichiosis and Lyme disease is also being recognised as an important feature of these tick-borne illnesses. Despite the superficial resemblance of Babesia to malaria, these piroplasms do not respond to chloroquine or other similar drugs. However, the treatment of babesiosis using a clindamycin-quinine combination has been successful. Data in animal models and case-reports in humans have suggested that an atovaquone-azithromycin combination is also effective. This was confirmed in a recent prospective, open, randomised trial of clindamycin-quinine versus azithromycin-atovaquone. This paper reviews the literature on the treatment of human babesiosis and the animal models of these human pathogens.

Antiparasitic agents

Several important developments have occurred in recent years in the chemotherapy for and prophylaxis of parasitic infections. Although mefloquine is clearly the most effective agent for prevention of chloroquine-resistant falciparum malaria, its use has been compromised by side effects, both real and imagined. Well-designed studies have shown that side effects occur no more frequently with low-dose mefloquine than with chloroquine. Use of mefloquine in pregnant women has not been associated with birth defects, but the incidence of stillbirths may be increased. Malarone is a new agent that combines atovaquone and proguanil, and it may be as effective as mefloquine; however, it is not yet available in the United States. Several newer agents have appeared in response to the development of multidrug resistant Plasmodium falciparum, especially in Southeast Asia. Halofantrine is available for the treatment of mild to moderate malaria due to P. falciparum and for P. vivax infections. Because of severe toxic effects, use of halofantrine should be restricted to only those unusual and rare situations in which other agents cannot be used. Artemisinin (an extract of the Chinese herbal remedy qinghaosu) and two derivatives, artesunate and artemether, are active against multidrug resistant P. falciparum and are widely used in Asia in oral, parenteral, and rectal forms. The antibacterial azithromycin in combination with atovaquone or quinine has now been reported to treat babesiosis effectively in experimental animals and in a few patients. Azithromycin in combination with paromomycin has also shown promise in the treatment of cryptosporidiosis (and toxoplasmosis when combined with pyrimethamine) in patients with the acquired immunodeficiency syndrome (AIDS). Albendazole is currently the only systemic agent available for treatment of microsporidiosis, an infection primarily of patients with AIDS. In addition, albendazole and ivermectin have emerged as effective broad-spectrum antihelminthics, with albendazole becoming the drug of choice for hydatid disease (echinococcosis), neurocysticercosis, and most intestinal nematode infections (except strongyloidiasis and trichuriasis). Liposomal amphotericin B is the first drug approved by the Food and Drug Administration for the treatment of visceral leishmaniasis.