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March 2010
Patient Care and Science
EIN: Immunosuppressed Patients and Norovirus

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds the EIN. The reader assumes all risks in using this information. 

A recent discussion on the EIN listserv suggested the need for additional research into treatment options for norovirus in immunosuppressed patients with a protracted illness. Currently, there is no vaccine to prevent norovirus infection and no drug to treat people who are infected. (This webpage from the Centers for Disease and Control and Prevention (CDC)’s division of viral diseases offers additional information about noroviruses for the public and for clinicians.)

A member in Florida asked,  “Has anyone had experience with immunosuppressed patients who have a prolonged illness with rotavirus or norovirus and used nitazoxanide?”

Putting the question in context, the member reported “seeing lots of gastroenteritis in my area among hospital staff, family and friends. One of our allogeneic BMT [bone-marrow transplant] patients admitted for dehydration and gastroenteritis tested positive for norovirus by PCR of stool.” The patient improved with hydration and time but was not on corticosteroids and was three years removed from his transplant. Another BMT patient experienced symptoms for a longer duration (two weeks) and “got much better with nitazoxanide 500mg po bid for one week, longer than the three-day usual course, which we instituted when the diagnosis was confirmed.”

The Florida member referenced three articles related to the use of nitazoxanide:

  • An April 2009 article from Clinical Medicine: Therapeutics, “Current Approaches to the Treatment of Gastrointestinal Infections: Focus on Nitazoxanide.”
  • An article from the November 2006 issue of Alimentary Pharmacology & Therapeutics, “Nitazoxanide in the treatment of viral gastroenteritis: a randomized double-blind placebo-controlled clinical trial.”
  • An International Journal of Infectious Diseases article from July 2009, “Nitazoxanide vs. probiotics for the treatment of acute rotavirus diarrhea in children: a randomized, single-blind, controlled trial in Bolivian children.”

A respondent in Florida noted an article and related editorial that appeared in the October 2009 issue of Clinical Infectious Diseases  and addressed allogeneic hematopoietic stem cell transplantation and norovirus gastroenteritis as a previously unrecognized cause of morbidity. “Nitazoxanide is not mentioned,” the respondent wrote.

A member in South Carolina asked if there had been “virologic confirmation of the etiology of the current apparently very widespread outbreak of a viral gastroenteritis syndrome in the last few weeks in the U.S.?”

The EIN member who posted the original question about nitazoxanide responded that a county health department on Florida’s Gulf Coast had reported outbreaks of norovirus in four chronic-care facilities and a nursing home. The member also referenced an October 2009 article in the New England Journal of Medicine about norovirus gastroenteritis. The article “never mentioned treatment with nitazoxanide, I assume because it’s a self-limited illness in the vast majority of people. Sounds like it’s a needed study in immunosuppressed patients with a protracted illness.”

More research may be needed in this area, as no EIN member was able to offer other suggestions for treatment of immunosuppressed individuals with prolonged illness.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public-health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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