17 / 83
I
s
sulfadiazine
alone
equivalent
(
benefit
and
harm
)
to
spiramycin
to
treat
acute
toxoplasmosis
in
the
first
trimester
of
pregnancy
?
R
ev
A
ssoc
M
ed
B
ras
2015; 61(6):495-496
495
AT BEDSIDE
Is sulfadiazine alone equivalent (benefit and harm) to spiramycin to
treat acute toxoplasmosis in the first trimester of pregnancy?
A
sulfadiazina
isolada
é
equivalente
(
benefício
e
dano
)
à
espiramicina
no
tratamento
da
toxoplasmose
aguda
no
primeiro
trimestre
da
gestação
?
W
anderley
M
arques
B
ernardo
1,2,3
, M
iriam
C
hinzon
3
, F
elipe
G
alvão
B
atista
C
haves
3
1
Associação Médica Brasileira
2
Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
3
Faculdade de Medicina, Centro Universitário Lusíada (Unilus), Santos, SP, Brazil
http://dx.doi.org/10.1590/1806-9282.61.06.495O
bjective
To evaluate, through a systematic review, if, whenever spi-
ramycin is not available to treat pregnant women with
acute toxoplasmosis in the first quarter of gestation, there
is an effective and safe treatment option for both moth-
er and fetus, especially in relation to isolated use of sul-
fadiazine.
M
ethods
Evidence eligibility criteria
Observational (prospective or retrospective cohort) or ex-
perimental (randomized or non-randomized trials) stud-
ies comparing forms of treatment of acute toxoplasmo-
sis in the first trimester of pregnancy.
No publication date limit. Languages: English, Por-
tuguese, Spanish and Italian.
Evidence search
Medline was the database consulted, using three differ-
ent and complementary search strategies: 1. pregnancy
AND sulfadiazine (171 studies retrieved); 2. (sulfadiazine)
AND Spiramycin AND (comparative study OR epidemi-
ologic methods OR therapy/broad[filter]) (63 studies re-
trieved); 3. toxoplasmosis AND sulfadiazine AND ran-
dom (41 studies retrieved).
R
esult
The combined search strategies led to the retrieval of 224
studies. After applying the eligibility criteria, based on ti-
tles and abstracts, 9 studies
1-9
were selected for critical
evaluation of texts.
Of the studies, 8 were observational cohorts (7 his-
torical and one prospective) and one systematic review.
Patients included in the evidence were pregnant women
with acute toxoplasmosis treated prenatally with spira-
mycin, sulfadiazine, pyrimethamine and folinic acid
(PSA), or sulfadiazine and pyrimethamine (SP) combined
with spiramycin. The rates of vertical transmission in
women infected in the 1
st
, 2
nd
and 3
rd
trimesters of preg-
nancy were 5, 13 and 32%, respectively. The rates of ver-
tical transmission in those treated only with spiramycin,
PSA, or PS combined with spiramycin were 13, 13 and
24% respectively.
No studies have compared spiramycin with sulfadi-
azine, or even used sulfadiazine as an isolated treatment
option.
D
iscussion
Congenital toxoplasmosis derives from fetal transmis-
sion of
Toxoplasma gondii
via placenta, as a result of acute
maternal infection. The infection is more severe in the
first trimester of pregnancy,
although the risk of vertical
transmission increases during pregnancy.
Early serological diagnosis in pregnant patients and
prenatal treatment, were significant factors to reduce the
risk of vertical transmission and the development of se-
quels in the infected child, including intracranial calcifi-
cation, eye injury and neurological impairment.
In case of seropositivity, the mother should be imme-
diately treated with spiramycin. There is controversy in
the literature regarding the duration of treatment and
whether other drugs should be associated. Spiramycin is
a macrolide antibiotic, which aims at the prevention of
fetal infection. It does not cross the blood-placental bar-
rier and, therefore, has no teratogenic effects to the fetus,
or toxicity to the mother. Given that the drug remains at
high levels in the placenta, it protects the fetus from con-
tact with the parasite. Spiramycin has no therapeutic ef-
fect on already infected fetus.
After 16 weeks of pregnancy, polymerase chain reac-
tion (PCR) of amniotic fluid is performed to confirm the
diagnosis of fetal infection. According to the studies, the
treatment of choice is the combination of sulfadiazine,
pyrimethamine, and folinic acid (PSA), with or without
spiramycin. The power of these drugs is higher, because
they can cross the blood-placental barrier.