Species-Directed Therapy for Leishmaniasis in Returning Travellers: A Comprehensive Guide

Abstract

BackgroundLeishmaniasis is increasingly reported among travellers. Leishmania species vary in sensitivity to available therapies. Fast and reliable molecular techniques have made species-directed treatment feasible. Many treatment trials have been designed poorly, thus developing evidence-based guidelines for species-directed treatment is difficult. Published guidelines on leishmaniasis in travellers do not aim to be comprehensive or do not quantify overall treatment success for available therapies. We aimed at providing comprehensive species-directed treatment guidelines.Methodology/Principal FindingsEnglish literature was searched using PubMed. Trials and observational studies were included if all cases were parasitologically confirmed, the Leishmania species was known, clear clinical end-points and time points for evaluation of treatment success were defined, duration of follow-up was adequate and loss to follow-up was acceptable. The proportion of successful treatment responses was pooled using mixed effects methods to estimate the efficacy of specific therapies. Final ranking of treatment options was done by an expert panel based on pooled efficacy estimates and practical considerations. 168 studies were included, with 287 treatment arms. Based on Leishmania species, symptoms and geography, 25 clinical categories were defined and therapy options ranked. In 12/25 categories, proposed treatment agreed with highest efficacy data from literature. For 5/25 categories no literature was found, and in 8/25 categories treatment advise differed from literature evidence. For uncomplicated cutaneous leishmaniasis, combination of intralesional antimony with cryotherapy is advised, except for L. guyanensis and L. braziliensis infections, for which systemic treatment is preferred. Treatment of complicated (muco)cutaneous leishmaniasis differs per species. For visceral leishmaniasis, liposomal amphotericin B is treatment of choice.Conclusions/SignificanceOur study highlights current knowledge about species-directed therapy of leishmaniasis in returning travellers and also demonstrates lack of evidence for treatment of several clinical categories. New data can easily be incorporated in the presented overview. Updates will be of use for clinical decision making and for defining further research.

Leishmaniasis in travelers: A literature review

“…To date an ideal anti-leishmanial agent is far from being discovered; its desirable features would be effectiveness, safety, ease of administration, and affordability. The recent paper by Hodiamont et al demonstrates the lack of evidence in the literature for treatment of several clinical categories with different Leishmania species [131]. The choice of treatment is influenced by previous experience as well as availability of a particular drug within a country.…”

Cutaneous Leishmania tropica in children: report of three imported cases successfully treated with liposomal amphotericin B

“…5 Local treatment with intralesional pentavalent antimony (PA) is considered the first-line therapy of CL caused by L.tropica unless there are multiple (>5), large (>4 cm) or disfiguring facial lesions. 6,7 In such cases, systemic treatment with intravenous PA or L-Amb, oral miltefosine or oral imidazoles is recommended. 8 Intravenous PA is most commonly used, but it requires long hospitalization and has potential severe sideeffects.…”

“…8 Intravenous PA is most commonly used, but it requires long hospitalization and has potential severe sideeffects. 6 In a recent retrospective study of 70 children with CL caused by L. tropica, efficacy and safety of intravenous PA and L-Amb were evaluated; the authors observed a superior cure rate and a shorter hospitalization period with L-AmB, proposing L-AmB as the first-line systemic therapy. 9 L-AmB is welltolerated, being is its high cost the main drawback.…”

Successful Treatment with Intralesional Meglumine Antimoniate in Recurrent Cutaneous Leishmaniasis: Case Report

“…In travelers returning from endemic areas, the combination of intralesional antimony with cryotherapy is recommended for the treatment of uncomplicated cutaneous leishmaniasis, except for L. guyanensis and L. braziliensis infections in which parenteral therapy is preferred [22].…”