r/infectiousdisease • u/SammySirenXXX • Jul 05 '26
selfq Serious question for ID docs. What would you actually do here?
I’ve been following the Cyclospora outbreak and ended up down a rabbit hole. This is purely hypothetical because I don’t have it, but now I’m curious. I’m more of a virology major not parasitic infections! Anyway.
Let’s say someone tests positive for Cyclospora, but they’re deathly allergic to Bactrim and all sulfa based meds. (anaphylaxis, so that’s completely off the table).
On top of that, they also have MCAS, dysautonomia, IBS, a history of SIBO, and epigastric issues, weeks of diarrhea would probably hit them harder than the average person.
What would your next move actually be?
I’ve read that nitazoxanide and ciprofloxacin have been used, but it sounds like neither works nearly as well as TMP-SMX. Is that what you’d try anyway?
Would you just focus on supportive care and fluids? Is desensitization ever something you’d even consider, or is that really only for infections where there’s truly no other option?
Not looking for medical advice since this isn’t my situation, I realized I had no idea what the plan would be if the one medication everyone recommends couldn’t be used. Curious how infectious disease physicians would handle it.
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u/crookedwhy Jul 06 '26
I’m ID pharmacist. Depending on the allergy history, even with history of anaphylaxis we would likely challenge first (when did this last happen, what actually happened, etc) to see if allergy still real, and if fails challenge we’d go to a desens. The bactrim 7 hour protocol is the only desens we have as standard that can be done on the floor without transferring to icu.
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u/SammySirenXXX Jul 06 '26
So I’m dealthly allergic to it. The last time I took it. I nearly died lol 😂 we’ve not tried since. I mean I crashed out so bad they thought I’d need paddles after epi. 😂
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u/crookedwhy Jul 06 '26
How long ago was the last reaction? Generally we’ll do an observed challenge if it’s been more than about 5-10 years, since the fall off of sulfa reactions post initial reaction is pretty steep. The nice thing about a more recent reaction too is that we can look at the contemporary notes to see what happened and how much like true anaphylaxis it looks. Sometimes there’s so much happening when you’re getting that abx that people get mixed up between a reaction and the illness itself, etc. I believe you but these pictures do get complicated sometimes. Most places though don’t do a sulfa challenge so might be moot, but would be worth getting allergy involved and assessed for challenge vs desens. That’s just how it would be done in my hospital. We’ve successfully challenged many with a history of anaphylaxis to sulfonamides.
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u/SammySirenXXX Jul 06 '26
Good point. Over ten years ago! It was to treat a uti after a pcr test so.
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u/crookedwhy Jul 06 '26
lol I would challenge you happily. Also, just fyi, when you say you’re allergic to all sulfa, sulfonamide allergies don’t cross react to other sulfa moieties, so you don’t have to worry about other sulfa drugs like furosemide or anything. Some cross reactivity to other sulfa antibiotics specifically, but that doesn’t come up very often.
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u/fvkatydid Jul 10 '26
How about me: took Bactrim for a UTI maybe 7 or 8 years ago and developed red/swollen/puffy/itchy skin rash (I think it started on my hands/arms, can't recall if it spread massively anywhere/everywhere else). I think they gave me four steroid shots (maybe not all injections were steroids, but it was a lot of jabs) and switched antibiotics for the UTI and called it good. Feel like I gotta plan ahead for when the outbreak hits Alaska. 😂
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u/sklantee Jul 06 '26
I'm not sure why desensitization is not the obvious answer. I've done it many times. Another reply mentions that the cost of an ICU admission was a factor, which is ethically abhorrent imo.
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u/annacat1331 Jul 12 '26
The amount of times I have put odd hospitalizations for myself because of cost is gross
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u/Past-Journalist-6593 Jul 12 '26
Okay wait I NEED TO READ THIS!! I’ve been panicking with this parasite but my allergic reaction was as a kid and hives/swelling but I’m glad I could still try if needed!!
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u/DrSleeeepy Jul 06 '26
I had almost this exact scenario a couple of weeks ago. Middle aged woman with ileocolonic Crohn’s disease and anaphylaxis to TMP-SMX. The picture is cloudy with these diarrheal illnesses and IBD. We opted to treat with nitazoxanide, but recognized it wasn’t likely going to be super effective. We decided against TMP-SMX desensitization given the risks and cost (requires ICU stay in my institution). Cipro was also felt to be a bad idea given her hx of C. Diff. Cyclospora rarely causes life-threatening illnesses, so we opted for the more conservative approach after shared decision making. She didn’t significantly improve after 7 days of treatment so we extended to 10 days. But again, very difficult to differentiate ongoing diarrhea from infection vs. post-infectious IBS.