The Use of Quinacrine in Nitroimidazole-resistant Giardia Duodenalis : An Old Drug for an Emerging Problem

<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background.</div>There is little evidence regarding the management of refractory giardiasis after treatment with nitroimidazoles. This study estimates the proportion of persistent giardiasis in 3 hospitals in Barcelona, describes associated risk factors and genotype, and evaluates the efficacy rate of quinacrine in those with persistent giardiasis.<div class="boxTitle">Methods.</div>A clinical, prospective, observational study was conducted in patients with giardiasis treated with nitroimidazoles. Those with persistent giardiasis were provided quinacrine. Molecular characterization of <span style="font-style:italic;">Giardia</span> isolates was performed by polymerase chain reaction amplification of a fragment of <span style="font-style:italic;">tpi</span> and <span style="font-style:italic;">bg</span> genes.<div class="boxTitle">Results.</div>Seventy-seven patients were recruited and treated with nitroimidazoles, and in 14 of 71 (20%) of patients followed up, <span style="font-style:italic;">Giardia</span> persisted. Refractory giardiasis was associated with malaise (<span style="font-style:italic;">P =</span> .007) and anorexia (<span style="font-style:italic;">P =</span> .02), with previous giardiasis (<span style="font-style:italic;">P =</span> .03), and with previous antibiotic (<span style="font-style:italic;">P =</span> .02) or antiparasitic(<span style="font-style:italic;">P =</span> .04) use. Quinacrine had an effectiveness rate of 100% in refractory giardiasis (n = 13; 95% confidence interval = 75–100). Molecular characterization showed that 17 (25%) <span style="font-style:italic;">Giardia</span> isolates belonged to assemblage A, and 31 (43%) belonged to assemblage B. In refractory giardiasis, assemblage A and B were found responsible in 4 and 6 cases, respectively.<div class="boxTitle">Conclusions.</div>Almost 20% of patients presented persistent giardiasis, belonging to both assemblages A and B, after nitroimidazole. Short course of quinacrine was effective in treating refractory cases. Further controlled studies should evaluate its efficacy and safety.</span>

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