Acta Tropica
journal homepage: www.elsevier.com/locate/actatropica
Academic Paediatric Hospital Pedro Borrs, Calle F No. 616 esquina 27, Plaza, La Habana CP 10400, Cuba
Working Group on Zoonoses, International Society for Chemotherapy, Aberdeen, United Kingdom
Committee on Clinical Parasitology, Panamerican Association of Infectology
d
University of the Basque Country, UPV/EHU and CIBERSAM, Medical SchoolDepartment of Neuroscience, Barrio Sarriena S/N, Leioa, Spain
e
Institute of Psychiatric Research, Ega
na 10, 48010 Bilbao, Spain
f
Municipal Centre of Hygiene, Epidemiology and Microbiology Plaza, Calle 8 No. 406 esquina a 19, Plaza, La Habana CP 10400, Cuba
b
c
a r t i c l e
i n f o
Article history:
Received 4 July 2015
Received in revised form
17 September 2015
Accepted 27 September 2015
Available online 22 October 2015
Keywords:
Giardia infection
Giardiasis
Children
Systematic review
Meta-analysis
a b s t r a c t
Metronidazole is frequently used against Giardia infection; however, it has been associated with signicant failure rates in clearing parasites from the gut; additionally, as it should be taken for 5 to 10 days, it is
associated with poor compliance, probably due to side effects. Other drugs, including tinidazole (TNZ) and
albendazole (ABZ) have been included in the antigiardial armamentarium. Our aim was to assess the efcacy of ABZ compared with TNZ in Giardia infections in children. A systematic review and a meta-analysis
were carried out. PubMed, Medline, EMBASE, CENTRAL, and LILACS were searched electronically until
February 2015. Also relevant journals and references of studies included therein were hand-searched
for randomised controlled trials (RCTs). The meta-analysis was limited to RCTs evaluating the use of ABZ
compared with TNZ in children with Giardia infection. The assessed outcome was parasitological efcacy.
Prediction intervals (PI) were computed to better express uncertainties in the effect estimates. Five RCTs
including 403 children were included. Overall, TNZ signicantly outperformed ABZ without differences
between subgroups dened by ABZ dosages [relative risk, (RR) 1.61 (95% CI): (1.401.85); P < 0.0001].
The 95% prediction interval range is 1.282.02. There was no signicant heterogeneity (I2 = 0%; Q-test of
heterogeneity P = 0.4507. The number-needed-to-treat, the average number of patients who need to be
treated with TNZ to gain one additional good outcome as compared with ABZ was 4, 95% CI: 35. Our
results show that TNZ outperforms ABZ in the treatment of Giardia infections in children from developing
countries.
2015 Elsevier B.V. All rights reserved.
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
2.1.
Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
2.2.
Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
2.3.
Study selection and data extraction process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
2.4.
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
2.5.
Evaluation of study quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
2.6.
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3.1.
Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3.2.
Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
121
3.3.
Parasitological examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
3.4.
Meta-analytical results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
3.5.
Sensitivity results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
4.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
4.1.
Limitations of study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
5.
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Conict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Authors contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Appendix A.
Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
1. Introduction
Giardia lamblia, a common single-celled intestinal parasite of
humans and animals, continues to be a signicant public health
problem, mainly in developing countries. Infection with this protozoan parasite occurs primarily by oral inoculation of faecally
excreted infective cysts either by person-to-person contact (including any form of sexual contact with proximity to faeces) or by
ingestion of contaminated food or water. Although most of the
persons who carry this protozoan remain symptomless, it has also
been increasingly implicated in the aetiology of a range of different
intestinal and extra-intestinal manifestations, including acute to
persistent and severe diarrhoea (with or without dehydration and
malabsorption), abdominal cramps, atulence, bloating, and nausea and, in the early childhood, the failure to thrive syndrome
(Escobedo et al., 2010).
Giardiasis, the disease this protozoan causes, occurs worldwide,
as research on its therapy, too. During the last years, research on giardiasis has been growing (Escobedo et al., 2015), maybe as a result
of its re-emergence in industrialized countries and the fact that it
was included in the World Health Organization (WHO) Neglected
Diseases Initiative from 2004 (Savioli et al., 2006). However, the
number of drugs available against this infection has not varied
substantially during the last decades. Five-nitroimidazole (5-NI)
compounds, mainly metronidazole (MTZ), have been the mainstay
of pharmacological treatment for patients with Giardia infection.
Their introduction in the antigiardial armamentarium constituted
a signicant improvement in giardiasis therapy. The long duration
of treatment with MTZ and its side effect prole (metallic taste,
headache, anorexia, nausea, vomiting) have been important disadvantages to its use. The other 5-NI compounds, including tinidazole
(TNZ), ornidazole and secnidazole, are effective when given as
a single dose and are associated with fewer side effects, which
reects their better acceptance. However, there is an increasing
number of treatment failures reported in the literature (McIntyre
et al., 1986; Lo Line Mei et al., 1987; Taylor et al., 1987; Al Karawi
et al., 1988; Rowedder et al., 1991; Elliott et al., 1998; Abboud
et al., 2001; Nash et al., 2001; Mrch et al., 2008; Kampitak, 2010;
Tejman-Yarden et al., 2013; Requena-Mndez et al., 2014; Meltzer
et al., 2014; Navarro et al., 2015). The interpretation and implications of these studies are still being debated, but they have led to
an increased awareness of Giardia resistance as a current clinical
problem. In addition to resistance, other potential causes of treatment failures include patient compliance (Shepherd and Boreham,
1989), poor quality of medicines, which includes spurious/falsely
labeled/falsied/counterfeit medicines, chemical and/or physicochemical instability, inappropriate storage and transport, and poor
quality control during manufacturing and importing medicines
(Heyman and Williams, 2011), reinfection, inadequate drug levels, immunosuppression, resistance to the drug, sequestration in
the gallbladder or pancreatic ducts, and unknown reasons (Nash
et al., 2001; Robertson et al., 2010). Consequently, newer and older
122
2.4. Outcome
The outcome measure was parasitological cured (dened as
above) at the end of the treatment in at least two consecutive faecal
microscopic examination performed at the last follow-up.
2.6. Analysis
Meta-analysis was used to calculate the pooled estimates of the
treatment efcacy, comparing TNZ vs ABZ. We used the I2 index to
estimate the proportion of total variability in point estimates that
could be attributed to between-trials heterogeneity, rather than
by a chance (Higgins et al., 2003). The relative risk (RR) was the
effect size to analyze with values >1 meaning TNZ was better than
ABZ. Individual effect sizes were combined by the MantelHaenszel
method using a random effects model and a predictive RR estimate
was obtained (Higgins et al., 2009).
Sensitivity analysis was performed to assess the consistency
of the overall ndings on the magnitude of the effect when trials
were removed one at the time from the full analysis set. This
would also allow us to check the impact of excluding the trial that
utilised the most insensitive parasitological methods, i.e. direct faecal microscopy with brine otation technique employed (Chan del
Pino et al., 1999). The latter method, unlike the ether sedimentation
method used in the rest of studies, is just a concentration technique
for the diagnosis of intestinal helminth infections, not for intestinal protozoa (Garca and Bruckner, 1993). A sensitivity analysis was
also performed with the two articles with follow-up longer than 14
days (Chan del Pino et al., 1999; Mendoza et al., 2003), considering
that faecal specimens at least in endemic countries should be
obtained during the rst 12 days after completion of therapy (the
number of days needed for a Giardia infection to become patent)
(Jokipii and Jokipii, 1977).
A small study bias analysis was planned only in case we retrieved
an appropriate number of studies for the meta-analysis (about 10).
All analyses were performed with the R package (R Core Team,
2014) using the meta library (Schwarzer, 2014).
3. Results
3.1. Study selection
The review process is shown in Fig. 1 and the selected papers
meeting the inclusion criteria are summarised it Table 1.
3.2. Study characteristics
Our search identied 5 RCTs which compared ABZ with TNZ, representing a total of 423 children with Giardia infection included for
the current review (Chan del Pino et al., 1999; Mendoza et al., 2003;
Pengsaa et al., 1999, 2002; Escobedo et al., 2003). Trials were published between 1999 and 2003. One trial was conducted in Peru;
two were conducted in Thailand and the other two in Cuba, all
of them are countries where Giardia infection is endemic. At the
last follow-up visit, 220 and 203 children were evaluated for ABZ
and TNZ, respectively. All studies were open label trials with random allocation of children to ABZ or TNZ. TNZ was prescribed at
a single 50 mg/kg dose. However, the dosages of ABZ ranged from
Table 1
Characteristics of the randomised controlled trials included in the meta-analysis.
Author, year (country)
Study design
Open-label, RCT
5 parallel arms
79
313
NS
Symptomatica
Diagnostic test
Antigiardial drug
regimens
(No. of
participants)
Efcacy
Follow-up
Day 7, 14 and 21
131
315
71/73
Symptomatic and
asymptomatic
Direct smear in
0.9% saline and
ether
sedimentation
method
TNZ, 50 mg (max.
2 g) s.d. (63)
Pengsaa (2002)
(Thailand)
Mendoza (2003)
(Cuba)
Open-label, RCT
3 parallel arms
Open-label, RCT
2 parallel arms
84
92
715
25
NS
47/45
Symptomatic
Symptomatic and
asymptomatic
Escobedo (2003)
(Cuba)
Open-label, RCT
3 parallel arms
165
215
58/57
Symptomatic
49/63 (77.8%)
13/26 (50%)
25/27 (92.6%)
TNZ, 50 mg (max.
2 g) s.d. (43)
Day 7, 14 and 21
after treatment
Pengsaa (1999)
(Thailand)
31/43
(72.0%)
37/60
(62.0%)
50/55
(91.0%)
As children were included after a screening may be some of them could be asymptomatic.
123
124
Table 2
Parasitological quality of included studies.
Study
Parasitological examination
Description
Adequate
Repeated
Interobserver variation
Totalb
2
2
2
2
2
0
3
3
3
3
3
3
3
3
3
0
0
0
0
0
5
8
8
8
8
Fig. 2. Forest plot showing the effects of albendazole and tinidazole in giardiasis in children.
not described in any trial. In 4 studies, the diagnosis of Giardia infection was based on direct faecal microscopy in combination with
ether concentration technique (Mendoza et al., 2003; Pengsaa et al.,
1999, 2002; Escobedo et al., 2003), and the remaining study (Chan
del Pino et al., 1999) used direct faecal microscopy in combination with brine otation technique, which is not specic for the
diagnosis of intestinal protozoa.
3.4. Meta-analytical results
In all ABZ dosage subgroups, TNZ signicantly outperformed
ABZ (see forest plot in Fig. 2). The overall RR estimate was 1.61
(95% CI: 1.40, 1.85) P < 0.0001. The 95% prediction interval range
for the RR was 1.282.02. There was no signicant heterogeneity
(I2 = 0%; Q-test of heterogeneity P = 0.4507).
The results did not vary by different dosages of ABZ (Qtest = 0.65, d.f = 2, P = 0.72). For 400 mg once a day for 5 days, the
RR was 1.55 (95% CI: 1.241.94), for 400 mg for 3 days the RR was
1.70 (95% CI: 1.272.28) and for 800 mg the RR was 1.85 (95% CI,
1.242.76).
We also evaluated the results on the risk difference (RD) scale
and its inverse, the number-needed-to-treat (NNT) to obtain one
more success with TNZ than the comparative arm. The RD of 0.33
(95% CI: 0.250.41) translates to a 33% higher efcacy for TNZ, with
a NNT of 4 (95% CI: 35). To put these estimates in perspective, if we
125
the rst option is the best, due to its advantages in terms of the
frequency of cure and the simplicity of the dosing regimen.
RR
95% CI
P value
1.65
1.71
1.56
1.60
1.58
1.61
[1.42; 1.91]
[1.42; 2.06]
[1.34; 1.81]
[1.33; 1.91]
[1.35; 1.84]
[1.40; 1.85]
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
126
Nnez,
F.A., Hernndez, M., Finlay, C.M., 1999. Longitudinal study of giardiasis in
three day care centres of Havana city. Acta Trop. 73, 237242.
Pasupuleti, V., Escobedo, A.A., Deshpande, A., Thota, P., Roman, Y., Hernandez, A.V.,
2014. Efcacy of 5-nitroimidazoles for the treatment of giardiasis: a systematic
review of randomized controlled trials. PLoS Negl. Trop. Dis. 8, e2733.
Paul, M., Leibovici, L., 2014. Systematic review or meta-analysis? Their place in the
evidence hierarchy. Clin. Microbiol. Infect. 20, 97100.
Pengsaa, K., Sirivichayakul, C., Pojjaroen-anant, C., Nimnual, S., Wisetsing, P., 1999.
Albendazole treatment for Giardia intestinalis infections in school children.
Southeast Asian J. Trop. Med. Public Health 30, 7883.
127