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Background <p>Nitroimidazole-refractory giardiasis is an increasing problem. We present data on efficacy of a treatment ladder and on clinical characteristics and assemblage types in nitroimidazole-refractory giardiasis.</p> Methods <p>We conducted a prospective clinical observational study of adult patients with giardiasis at four centres in Norway and England during 2009 – 2024. Patients with nitroimidazole-refractory giardiasis were treated with albendazole plus a 5-nitroimidazole followed by quinacrine (mepacrine) if failure. Treatment efficacy was defined as negative stool microscopy and/or PCR four to six weeks after treatment. For analyses of assemblage types and risk factors for treatment failure, patients from a previously published Swiss treatment study were additionally included. Assemblage typing of <i>Giardia</i> isolates was performed collectively in the same laboratory by real-time PCR targeting the glutamate dehydrogenase gene (gdh). Predictors identified by univariate analyses were analysed by multivariate logistic regression for association with nitroimidazole failure.</p> Results <p>A total of 120 patients were prospectively included; 59 of these had nitroimidazole refractory giardiasis and were treated according to the treatment ladder. In addition, 20 patients from the Swiss cohort were included for assemblage and risk factor analyses. A repeated course of nitroimidazole cured only 24% (5/21). Metronidazole or tinidazole in combination with albendazole cured 76% (35/46). Quinacrine was effective in 100% (15/15). Assemblage B was more common in travellers from India and Africa, but only acquisition of infection in India (aOR 11.9; 95%CI 2.94, 47.6) and more recent year of diagnosis (aOR 1.18, 95% CI 1.03, 1.35) were associated with nitroimidazole failure in multivariate analysis.</p> Conclusion <p>Second line treatment with nitroimidazole in combination with albendazole, and third line treatment with quinacrine, are effective options in nitroimidazole-refractory giardiasis. Nitroimidazole failure seems to be highly associated with infection acquired in India, but not with assemblage A or B. Further studies of resistance mechanisms are needed.</p>

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Nitroimidazole - albendazole combination therapy, quinacrine use, and risk factors in nitroimidazole-refractory giardiasis: a prospective multicentre observational study

  • 期刊论文

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  • 发表日期：

    2026年6月20日

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  • Kristine Mørch,
  • Peter Chiodini,
  • Laura Nabarro,
  • Raisa Hannula,
  • Andreas Neumayr,
  • Christel Gill Haanshuus,
  • Christina Saghaug,
  • Bjørn Blomberg,
  • Frank Olav Dahler Pettersen,
  • Helene Heitmann Sandnes,
  • Kurt Hanevik,
  • Nina Langeland

摘要

Background

Nitroimidazole-refractory giardiasis is an increasing problem. We present data on efficacy of a treatment ladder and on clinical characteristics and assemblage types in nitroimidazole-refractory giardiasis.

Methods

We conducted a prospective clinical observational study of adult patients with giardiasis at four centres in Norway and England during 2009 – 2024. Patients with nitroimidazole-refractory giardiasis were treated with albendazole plus a 5-nitroimidazole followed by quinacrine (mepacrine) if failure. Treatment efficacy was defined as negative stool microscopy and/or PCR four to six weeks after treatment. For analyses of assemblage types and risk factors for treatment failure, patients from a previously published Swiss treatment study were additionally included. Assemblage typing of Giardia isolates was performed collectively in the same laboratory by real-time PCR targeting the glutamate dehydrogenase gene (gdh). Predictors identified by univariate analyses were analysed by multivariate logistic regression for association with nitroimidazole failure.

Results

A total of 120 patients were prospectively included; 59 of these had nitroimidazole refractory giardiasis and were treated according to the treatment ladder. In addition, 20 patients from the Swiss cohort were included for assemblage and risk factor analyses. A repeated course of nitroimidazole cured only 24% (5/21). Metronidazole or tinidazole in combination with albendazole cured 76% (35/46). Quinacrine was effective in 100% (15/15). Assemblage B was more common in travellers from India and Africa, but only acquisition of infection in India (aOR 11.9; 95%CI 2.94, 47.6) and more recent year of diagnosis (aOR 1.18, 95% CI 1.03, 1.35) were associated with nitroimidazole failure in multivariate analysis.

Conclusion

Second line treatment with nitroimidazole in combination with albendazole, and third line treatment with quinacrine, are effective options in nitroimidazole-refractory giardiasis. Nitroimidazole failure seems to be highly associated with infection acquired in India, but not with assemblage A or B. Further studies of resistance mechanisms are needed.