Evaluation Of Nitazoxanide Treatment Following Triclabendazole Failure In An Outbreak Of Human Fascioliasis In Upper Egypt (Vol 13, E0007779, 2019)

Author summary Fascioliasis is a neglected zoonosis with major public health implications in humans. Triclabendazole (TCBZ) is the drug of choice, but alternative approved drugs are necessary in cases of TCBZ failure. Nitazoxanide (NTZ) is an alternative used in such cases. However, the efficacy of NTZ in TCBZ-failure cases among patients in Egypt remains unclear. In this study, the efficacy of NTZ was evaluated in cases of TCBZ failure during an outbreak of human fascioliasis in Assiut governorate of Upper Egypt. This study enrolled 67 patients diagnosed with fascioliasis based on clinical, laboratory, and radiological findings. These patients were referred from the outpatient clinic in Manfalout locality of Assiut governorate in Egypt. All patients received TCBZ at recommended doses as initial treatment. Those failing to respond were treated with NTZ at standard doses; following therapy, lesions in the liver and high eosinophil counts were resolved in 30% and 6.7% patients, respectively, indicating an overall efficacy of 36.6%. Therefore, in this outbreak of human fascioliasis in Upper Egypt, NTZ was found to be partially effective in cases with TCBZ failure. Background Fascioliasis is a neglected zoonosis with major public health implications in humans. Although triclabendazole (TCBZ) is the drug of choice, there are records of TCBZ failure worldwide. TCBZ-resistant fascioliasis is treated with alternative approved drugs including nitazoxanide (NTZ), with varying levels of efficacy. Data on NTZ efficacy after TCBZ failure in Egypt is scarce. This study evaluated the efficacy of NTZ in cases of TCBZ failure during an outbreak of fascioliasis in Assiut governorate of Upper Egypt. Methodology/Principal findings This prospective study included 67 patients from the outpatient clinic in Manfalout locality of Assiut governorate with clinical manifestations of acute fascioliasis. These included high eosinophilia (> 6% eosinophils in peripheral blood), positive anti-Fasciola antibodies, and hepatic focal lesions (HFL) or ascites on abdominal ultrasound or computed tomography. All patients initially received TCBZ at recommended doses. Patients were followed up after 1 month to assess response. According to the responses, patients were categorized as non-responders and responders. The non-responders received a trial of NTZ and were re-assessed for response based on clinical manifestations, eosinophil count, and abdominal ultrasound. Patients not responding to NTZ received additional doses of TCBZ. One month after initial TCBZ treatment, 37 patients responded well to TCBZ, while 30 patients failed to respond with persistence of fever, abdominal pain, high eosinophilia, and HFL. Most non-responders were male (56.7%); females predominated among TCBZ responders (62.2%). The mean age of the non-responders was relatively lower, at 20.57 +/- 14.47 years (p = 0.004). Following NTZ therapy, HFL disappeared in 9/30 (30%) patients and eosinophil counts normalized in only 2 (6.7%) patients, indicating an overall efficacy of 36.6%. The remaining cases received additional doses of TCBZ with complete clinical, pathological, and radiological resolution.