Continuing Education Activity

Giardiasis is a small intestinal infection caused by the protozoa Giardia duodenalis. A common disease, it often presents with watery diarrhea and flatulence. This activity reviews the evaluation and treatment of giardiasis and explains the role of the interprofessional team to improve care for patients with this condition.

Objectives:

• Review the epidemiology of giardiasis.
• Describe the use of stool antigen detection assays and nucleic acid amplification tests (NAAT) in the evaluation of giardiasis.
• Outline the use of metronidazole as a first-line treatment for giardiasis.
• Summarize the importance of improving care coordination among the interprofessional team members to enhance the delivery of care for patients affected by giardiasis.

Introduction

Giardiasis is an enteric infection caused by the protozoa Giardia duodenalis. A common disease in low-resource settings, it often presents with flatulence and watery diarrhea. In the United States, the disease is most often seen in international travelers, wilderness travelers, and daycare workers. Though often asymptomatic, patients may have severe enough symptoms to result in dehydration and weight loss. Treatment with a nitroimidazole or antihelminthic medication is often rapidly curative.[1][2][3]

Etiology

Giardiasis is caused by the protozoa Giardia duodenalis (also referred to as Giardia lamblia and Giardia intestinalis). Infected animals excrete cysts into freshwater, where they are immediately infective and can exist for weeks to months. Seven genetic assemblages (A-F) have been identified, with only genotypes A and B being known to infect humans.[4][5][6]

Ingesting cysts through contaminated water or person-to-person direct contact causes human infection. Inadequate hygiene and sanitation play a vital role in transmission. Nowadays, daycares have become epicenters of the infection mainly through lack of proper handwashing while handling and changing diapers.[7] The cysts undergo excystation within the intestinal system and subsequently release trophozoites. Trophozoites appear as pear-shaped flagellated protozoa with two nuclei.

Epidemiology

Giardiasis is the most common enteric protozoal infection worldwide, affecting nearly 2% of adults and 8% of children in developed countries. Also, estimates show that almost 33% of the population in developing countries have been infected with giardiasis. The prevalence within the United States is estimated to be roughly 1.2 million, with the majority of cases not identified due to the carrier being asymptomatic. The Centers for Disease Control and Prevention (CDC) reported 15,223 cases submitted in 2012. The largest reported affected demographic was children 0 to 4 years of age, with the largest percentage of cases being reported from the northwest United States. Peak incidence occurs in late summer and early fall due to outdoor water activities.[8]

Protozoa are spread through the fecal-oral route, most commonly through the ingestion of contaminated water or food. It can also be spread through person-to-person or, less commonly, animal-to-person. An infected individual can shed nearly 10^8 to 10^10 cysts per day, while the infectious dose can be as low as 10. Individuals with a sub-clinical disease can serve as carriers and may infect others. Within the United States, populations at risk include international travelers, wilderness travelers, daycare workers, men who have sex with men, and professions with contact with human waste.[9]

Pathophysiology

The cause of symptoms in giardiasis is poorly understood. Trophozoites have a ventral disk that they use to adhere to the intestinal epithelium. Researchers theorize that the protozoa disrupt small intestine epithelial cell junctions as well as brush border enzymes. Affected patients can demonstrate altered gastrointestinal motility. The protozoa release thiol proteinases and lectins that have a cytopathic effect. The combination of these effects increases permeability and decreases the ability to process saccharides.[10]

Histopathology

A biopsy is seldom warranted in the evaluation of suspected giardiasis. However, when obtained in the evaluation of chronic diarrhea, histopathology will reveal normal to sub-total villous atrophy, with the degree of atrophy correlating with the severity of the disease. Repeat biopsy following treatment and improvement of symptoms will typically reveal the resolution of the villous atrophy.[11]

History and Physical

Nearly half of infected individuals are asymptomatic. For those with symptoms, the onset is typically 1 to 2 weeks after infection. Symptoms may include abdominal pain, nausea, flatulence, and large volume watery, foul-smelling, greasy stools. Children may present with abdominal pain with minimal diarrhea. Due to a large number of stools, infected individuals will often be dehydrated.[12] Less commonly, patients may also present with fever. Cases involving skin lesions and joint pain due to reactive arthritis have also been reported. Symptoms typically self-resolve within four weeks of onset. In chronic infections, individuals may present with weight loss and signs or symptoms of vitamin deficiency.

The CDC recommends that providers consider giardiasis in the differential diagnosis of all individuals with more than three days of diarrhea. Patients should be asked about risk factors such as recent international or wilderness travel, contact with unsanitary water, daycare work, and sexual practices.[13] Women of reproductive age should be screened for pregnancy, as this will affect treatment options.[14]

Physical examination is most often benign and often only reveals mild dehydration. Fevers are not common but may occur. Mild but diffuse abdominal tenderness to palpation may be present, and borborygmi may be apparent on auscultation. Providers should assess for possible skin manifestations such as hives or granuloma annulare.[15]

Evaluation

Stool antigen detection assays and nucleic acid amplification tests (NAAT) are available and are typically quicker and more sensitive, and specific than microscopy.[16] Giardia may be difficult to detect with microscopy as the protozoa are only intermittently shed. The sensitivity of microscopy can be increased by collecting three stool samples on different days.[17] Standard ova and parasite laboratory testing does not always include giardia testing, so the CDC recommends providers specifically request testing for giardia when submitting stool samples. As the differential for giardiasis includes other parasitic diseases, microscopy should be performed even when antigen or NAAT tests are obtained.

Treatment / Management

The majority of presenting patients will be non-toxic and may only require oral rehydration for initial fluid resuscitation. In more severe cases, intravenous (IV) fluids may be needed.[18][19]

Metronidazole is the first-line treatment for giardiasis.[20] Typical dosing is 250 to 500 mg 3 times a day for 5 to 10 days, though studies indicate once-daily dosing may be as effective. Metronidazole should be used with caution in pregnant women, especially in the first trimester, due to concerns for cleft lip. Also, patients should be counseled on avoiding alcohol due to the disulfiram effect (flushing, headaches, and nausea). Metronidazole can also be safely used in children in a typical dose of 30 mg/kg to 50 mg/kg per day divided into three doses.

Other possible regimens include tinidazole, nitazoxanide, mebendazole, albendazole, and paromomycin. Paromomycin is poorly systemically absorbed and may be considered if giardiasis needs to be treated in a pregnant patient in her first trimester.[21]

Data appears to be conflicting about the most effective treatment. A systematic review found that albendazole may be as effective as metronidazole with fewer side effects.[22] If patients continue to have symptoms despite therapy, a medication from another class should be used.

Differential Diagnosis

The differential diagnosis for giardiasis includes:

• Travelers' diarrhea
• Lactose intolerance
• Inflammatory bowel disease[23]
• Cryptosporidiosis
• Tropical sprue
• Irritable bowel syndrome[24]
• Strongyloidiasis
• Viral gastroenteritis

The CDC recommends testing all individuals with diarrhea lasting more than three days for giardiasis.

Complications

Giardiasis can lead to complications, including irritable bowel syndrome, chronic fatigue syndrome, food allergies, and even reactive arthritis.[25] Patients presenting with these conditions should be screened for possible giardia exposure.

Deterrence and Patient Education

Giardia cysts are resistant to chlorination. Iodine can be used for disinfection but may take up to 8 hours before the water is safe for drinking. Filters are also available. Travelers should ensure filters meet the National Safety Foundation (NSF) Standard 53 or NSF Standard 58 ratings for oocyst or cyst reduction. Boiling water for 10 minutes also kills the cysts.[26]

Enhancing Healthcare Team Outcomes

Giardiasis is a relatively common enteric infection caused by the protozoa Giardia duodenalis. The majority of patients present with watery diarrhea and abdominal cramps. Emergency department providers, nurse practitioners, and primary caregivers need to know that hydration is the key in all patients. Only those with severe symptoms need anti-helminthic medications. If there is any doubt about the diagnosis or management, an infectious disease expert should be consulted. Following treatment, symptoms subside rapidly, but a few patients may develop sensitivity to dairy products for a few weeks or months.