Ingestion of undercooked meats that could contain tissue cysts and contact with cat feces that could contain sporulated oocysts should be avoided (AIII).
Toxoplasma-seropositive children aged <6 years with CD4 T lymphocyte (CD4) cell percentage <15% and children aged ≥6 years with CD4 <100 cells/mm3 should be administered prophylaxis against Toxoplasma encephalitis (TE) (AIII). The preferred agent for prophylaxis of TE is trimethoprim-sulfamethoxazole, one double-strength tablet daily for adolescents and adults (or weight-equivalent dosing for children) (AII*).
Most experts recommend treating pregnant women with acute toxoplasmosis in an attempt to prevent fetal infection (BII). For more extensive information on diagnosis, prevention, and treatment of pregnant women with toxoplasmosis, please see the Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents.
Empiric therapy should be strongly considered for newborns of HIV-infected mothers who had symptomatic or asymptomatic primary Toxoplasma infection during pregnancy, regardless of whether treatment was administered during pregnancy (BIII).
The preferred treatment for congenital toxoplasmosis is pyrimethamine combined with sulfadiazine, with supplementary leucovorin (AII).
The recommended duration of treatment of congenital toxoplasmosis in HIV-infected infants is 12 months (AIII).
Therapy for acquired toxoplasmosis in HIV-infected children is sulfadiazine plus pyrimethamine and leucovorin (AI*). Please refer to http://www.daraprimdirect.com for information regarding access to pyrimethamine. If pyrimethamine is unavailable clinicians may substitute trimethoprim-sulfamethoxazole, dosed according to age and weight, in place of the combination of sulfadiazine, pyrimethamine, and leucovorin.
Corticosteroids are recommended for HIV-infected children with central nervous system toxoplasmosis when cerebrospinal fluid protein is highly elevated (i.e., >1,000 mg/dL) or who have focal lesions with substantial mass effect (BIII). Anticonvulsants should be administered only to children with TE who have a history of or current seizures (AIII).
Complete blood count should be monitored weekly in patients taking daily pyrimethamine (AIII). Patients who have completed initial therapy for TE should be given suppressive therapy (i.e., secondary prophylaxis or chronic maintenance therapy) unless cART results in immune reconstitution (AI*).
The preferred regimen for suppressive therapy for TE is sulfadiazine plus pyrimethamine and leucovorin (AI*). Please refer to http://www.daraprimdirect.com for information regarding access to pyrimethamine. If pyrimethamine is unavailable clinicians may substitute trimethoprim-sulfamethoxazole dosed according to age and weight.
For infants born to mothers with symptomatic Toxoplasma infection during pregnancy, empiric therapy of the newborn should be strongly considered irrespective of the mother's treatment during pregnancy.
Pyrimethamine use requires CBC monitoring at least weekly while on daily dosing and at least monthly while on less than daily dosing.
TMP-SMX—TMP 5 mg/kg body weight plus SMX 25 mg/kg body weight per dose IV or by mouth given twice daily has been used as an alternative to pyrimethamine-sulfadiazine in adults, but has not been studied in children.
Atovaquone (for adults, 1.5 g by mouth twice daily—double the prophylaxis dose) in regimens combined with pyrimethamine/leucovorin, with sulfadiazine alone, or as a single agent in patients intolerant to both pyrimethamine and sulfadiazine, has been used in adults, but these regimens have not been studied in children.
Azithromycin (for adults, 900–1,200 mg/day, corresponding to 20 mg/kg/day in children) has also been used in adults combined with pyrimethamine-sulfadiazine, but has not been studied in children.
Corticosteroids (e.g., prednisone, dexamethasone) have been used in children with CNS disease when CSF protein is very elevated (>1,000 mg/dL) or there are focal lesions with significant mass effects, with discontinuation as soon as clinically feasible.
Anticonvulsants should be administered to patients with a history of seizures and continued through the acute treatment; but should not be used prophylactically.
* Note: Sulfadiazine may be given as 2–4 equal doses per day as long as the total daily dose is 85–120 mg/kg body weight.