{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T12:18:46Z","timestamp":1788437926939,"version":"build-2803163510"},"reference-count":40,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,6,20]],"date-time":"2026-06-20T00:00:00Z","timestamp":1781913600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":75,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"University of Bergen"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Infect Dis"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Nitroimidazole-refractory giardiasis is an increasing problem. We present data on efficacy of a treatment ladder and on clinical characteristics and assemblage types in nitroimidazole-refractory giardiasis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We conducted a prospective clinical observational study of adult patients with giardiasis at four centres in Norway and England during 2009 \u2013 2024. Patients with nitroimidazole-refractory giardiasis were treated with albendazole plus a 5-nitroimidazole followed by quinacrine (mepacrine) if failure. Treatment efficacy was defined as negative stool microscopy and\/or PCR four to six weeks after treatment. For analyses of assemblage types and risk factors for treatment failure, patients from a previously published Swiss treatment study were additionally included. Assemblage typing of\n                      <jats:italic>Giardia<\/jats:italic>\n                      isolates was performed collectively in the same laboratory by real-time PCR targeting the glutamate dehydrogenase gene (gdh). Predictors identified by univariate analyses were analysed by multivariate logistic regression for association with nitroimidazole failure.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 120 patients were prospectively included; 59 of these had nitroimidazole refractory giardiasis and were treated according to the treatment ladder. In addition, 20 patients from the Swiss cohort were included for assemblage and risk factor analyses. A repeated course of nitroimidazole cured only 24% (5\/21). Metronidazole or tinidazole in combination with albendazole cured 76% (35\/46). Quinacrine was effective in 100% (15\/15). Assemblage B was more common in travellers from India and Africa, but only acquisition of infection in India (aOR 11.9; 95%CI 2.94, 47.6) and more recent year of diagnosis (aOR 1.18, 95% CI 1.03, 1.35) were associated with nitroimidazole failure in multivariate analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Second line treatment with nitroimidazole in combination with albendazole, and third line treatment with quinacrine, are effective options in nitroimidazole-refractory giardiasis. Nitroimidazole failure seems to be highly associated with infection acquired in India, but not with assemblage A or B. Further studies of resistance mechanisms are needed.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12879-026-13833-2","type":"journal-article","created":{"date-parts":[[2026,6,20]],"date-time":"2026-06-20T09:57:23Z","timestamp":1781949443000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Nitroimidazole - albendazole combination therapy, quinacrine use, and risk factors in nitroimidazole-refractory giardiasis: a prospective multicentre observational study"],"prefix":"10.1186","volume":"26","author":[{"given":"Kristine","family":"M\u00f8rch","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Chiodini","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Nabarro","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raisa","family":"Hannula","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Neumayr","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christel Gill","family":"Haanshuus","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christina","family":"Saghaug","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bj\u00f8rn","family":"Blomberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank Olav Dahler","family":"Pettersen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helene Heitmann","family":"Sandnes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kurt","family":"Hanevik","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina","family":"Langeland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,20]]},"reference":[{"issue":"1","key":"13833_CR1","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1186\/1471-2458-6-141","volume":"6","author":"K Nygard","year":"2006","unstructured":"Nygard K, Schimmer B, Sobstad \u00d8, Walde A, Tveit I, Langeland N, et al. 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The J Infect Dis. 1987;156(6):974\u201384. https:\/\/doi.org\/10.1093\/infdis\/156.6.974.","journal-title":"The J Infect Dis"}],"container-title":["BMC Infectious Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12879-026-13833-2","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12879-026-13833-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12879-026-13833-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T12:02:47Z","timestamp":1788436967000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12879-026-13833-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,20]]},"references-count":40,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["13833"],"URL":"https:\/\/doi.org\/10.1186\/s12879-026-13833-2","relation":{},"ISSN":["1471-2334"],"issn-type":[{"value":"1471-2334","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,20]]},"assertion":[{"value":"10 February 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 June 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 June 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Written informed consent was obtained from the patients. The patients were informed about the treatment and potential side effects and were treated and monitored according to clinical practice. The study was approved by the Regional Ethics Committees in Norway (2013\/1285\/REK vest), England (IRAS 228,436 \u2013 REC 18\/NW\/0630) and Switzerland (Ethics Commission Northwest and Central Switzerland - Ref Nr. 2014\u2013112). The study was carried out in accordance with the Declaration of Helsinki.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"1598"}}