Guideline for the Treatment of Leishmaniasis in the Americas. Second Edition

Abstract

Leishmaniases are neglected infectious diseases of great importance in the Americas because of their morbidity, mortality, and wide geographical distribution. Out of the three main clinical forms of leishmaniasis, cutaneous leishmaniasis is the most common and the visceral form is the most severe, causing death in up to 90% of untreated people. In 2013, the Pan American Health Organization (PAHO) developed recommendations for the treatment of leishmaniases in the Americas using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. However, given the new evidence that has accumulated since that time, there was a need to revise those recommendations. This second edition presents updated therapeutic recommendations for leishmaniases, detailing the treatment indications, criteria and schemes in the regional context. These guidelines include several notable changes from the first edition. For cutaneous leishmaniasis, ketoconazole has been removed from the list of treatment options; the number of Leishmania species for which there is strong evidence for the efficacy of miltefosine has increased from two to four; and the recommendation for intralesional antimonials is now strong. For mucosal leishmaniasis there is now a strong recommendation for use of pentavalent antimonials with or without oral pentoxifylline. For visceral leishmaniasis, the strong recommendations for use of pentavalent antimonials and amphotericin B deoxycholate are now conditional. For miltefosine, there is strong evidence against its usage in patients with leishmaniasis caused by Leishmania infantum. Further important changes include the division of recommendations by adult and pediatric populations, the addition of Leishmania species, and for immunocompromised patients, a strong recommendation against the use of pentavalent antimonials.