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acid (10 20 mg orally once daily) to prevent bone marrow suppression Patients should be screened for a history of sulfonamide sensitivity (skin rashes, gastrointestinal symptoms, hepatotoxicity) To prevent crystal-induced nephrotoxicity, good urinary output should be maintained; alkalinization with sodium bicarbonate may also be useful Pyrimethamine side effects include headache and gastrointestinal symptoms Even with folinic acid therapy, bone marrow suppression may occur; platelet and white blood cell counts should be monitored at least weekly A first-line alternative to sulfadiazine is clindamycin (600 mg orally four times daily) Other possible alternatives are trimethoprim-sulfamethoxazole or combining pyrimethamine with atovaquone, clarithromycin, azithromycin, or dapsone Pyrimethamine is not used during the first trimester of pregnancy due to its teratogenicity Standard therapy for the treatment of acute toxoplasmosis during pregnancy is with spiramycin (1 g orally three times daily until delivery) This therapy is used only to decrease the risk of fetal infection; it reduces the frequency of transmission to the fetus by about 60% Spiramycin does not cross the placenta, so when fetal infection is documented or for acute infections late in pregnancy (which commonly lead to fetal transmission) treatment with combination regimens as described above is indicated
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Prevention of primary infection centers on avoidance of undercooked meat or contact with material contaminated by cat feces, particularly for seronegative pregnant women and immunocompromised persons For meat, irradiation, cooking to 66 C, or freezing to 20 C kills tissue cysts Thorough cleaning of hands and surfaces is needed after contact with raw meat or areas contaminated by cats Oocysts passed in cat feces can remain infective for a year or more, but fresh oocysts are not infective for 48 hours For best protection, litter boxes should be changed daily and soaked in boiling water for 5 minutes In addition, gloves should be worn when gardening, fruits and vegetables should be thoroughly washed, and ingestion of dried meat should be avoided Universal screening of pregnant women for T gondii antibodies is conducted in some countries but not the United States Pregnant women should ideally have their serum examined for IgG and IgM antibody, and those with negative titers should adhere to the prevention measures described above Seronegative women who continue to have environmental exposure should undergo repeat serologic screening several times during pregnancy For immunocompromised individuals, chemoprophylaxis to prevent primary or reactivated infection is warranted For transplant recipients, pyrimethamine (25 mg daily for 6 weeks) has been used For advanced AIDS patients and others, chemoprophylaxis with trimethoprim-sulfamethoxazole (one double-strength tablet daily or two tablets three times weekly), used primarily for protection against Pneumocystis, is also effective against T gondii Alternatives are pyrimthamine plus either sulfadoxine or dapsone (various regimens)
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Therapy is generally not necessary in immunocompetent persons, since primary illness is self-limited However, for severe, persistent, or visceral disease, treatment for 2 4 weeks may be considered Treatment is appropriate for primary infection during pregnancy because the risk of fetal transmission or the severity of congenital disease may be reduced For retinochoroiditis, most episodes are self-limited, and opinions vary on indications for treatment Treatment is often advocated for episodes with decreases in visual acuity, multiple or large lesions, macular lesions, significant inflammation, or persistence for over a month Immunocompromised patients with active infection must be treated For those with transient immunodeficiency, therapy can be continued for 4 6 weeks after cessation of symptoms For those with persistent immunodeficiency, such as AIDS patients, full therapy for 4 6 weeks is followed by maintenance therapy with lower doses of drugs Immunodeficient patients who are asymptomatic but have a positive IgG serologic test should receive long-term chemoprophylaxis
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Drugs for toxoplasmosis are active only against tachyzoites, so they do not eradicate infection Standard therapy is the combination of pyrimethamine (200 mg loading dose, then 50 75 mg (1 mg/kg) orally once daily) plus sulfadiazine (1 15 g orally four times daily), with folinic
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