Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

accidental exposure and infection: nonpregnant without severe renal/hepatic insufficiency

1st line – antiparasitic treatment

Back
INITIAL
|
accidental exposure and infection: nonpregnant without severe renal/hepatic insufficiency
|
high risk
1st line – 

antiparasitic treatment

Recommended in all patients with accidental high-risk contaminations (e.g., contact with living parasites or cultures through skin breaks or mucosal membranes in laboratory/clinical/necroscopy settings).[2]

Benznidazole is the recommended first-line treatment as it is more widely available, is better tolerated, and has more efficacy data. Nifurtimox is an alternative option.[2]

Both drugs are contraindicated in pregnancy and severe hepatic/renal impairment. A negative pregnancy test is required before starting treatment in women of childbearing potential.

Adverse effects are more frequent and severe with increasing age and include: allergic dermatitis, peripheral neuropathy, weight loss, insomnia, leukopenia (benznidazole); polyneuropathy, nausea/vomiting, headache, dizziness/vertigo, and weight loss (nifurtimox). A complete blood count is recommended 21 days after starting treatment with benznidazole to monitor for leukopenia.[2] CDC: Chagas disease: antiparasitic treatment Opens in new window 

Availability varies across countries. In the US, benznidazole is approved in children 2 to 12 years of age and is available here: Exeltis: benznidazole tablets Opens in new window Nifurtimox is now also commercially available in the US, and no longer needs to be obtained from the Centers for Disease Control and Prevention.[172] In other countries, the drugs are available from local health regulatory agencies such as the World Health Organization.[173]

Treatment course: 60 days (benznidazole); 60-90 days (nifurtimox).

Primary options

benznidazole: children <2 years of age: consult specialist for guidance on dose; children 2-12 years of age: 5-8 mg/kg/day orally given in 2 divided doses; children >12 years of age and adults: 5-7 mg/kg/day orally given in 2 divided doses

Secondary options

nifurtimox: children <1 year of age: consult specialist for guidance on dose; children 1-10 years of age: 15-20 mg/kg/day orally given in 3-4 divided doses; children 11-16 years of age: 12.5 to 15 mg/kg/day orally given in 3-4 divided doses; children ≥17 years of age and adults: 8-10 mg/kg/day orally given in 3-4 divided doses

1st line – serologic monitoring

Back
INITIAL
|
accidental exposure and infection: nonpregnant without severe renal/hepatic insufficiency
|
low risk
1st line – 

serologic monitoring

Antiparasitic treatment is not recommended in low-risk exposures (e.g., contact with the blood of a chronically infected patient); however, serologic monitoring is recommended.

accidental exposure and infection: pregnant or with severe renal/hepatic disease

1st line – serologic monitoring

Back
INITIAL
|
accidental exposure and infection: pregnant or with severe renal/hepatic disease
1st line – 

serologic monitoring

Antiparasitic therapy is contraindicated in pregnant women or patients with severe hepatic/renal impairment. Therefore, serologic monitoring is recommended in these patients, regardless of exposure risk. Antiparasitic treatment may be started in pregnant women after birth, or in patients with severe hepatic/renal impairment if their organ function improves.

ACUTE

acute infection

1st line – antiparasitic treatment

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ACUTE
|
acute infection
|
nonpregnant without severe renal/hepatic insufficiency
1st line – 

antiparasitic treatment

Recommended in all patients with acute phase of infection (including congenital infection), regardless of mode of transmission.[2]

Benznidazole is the recommended first-line treatment as it is more widely available, is better tolerated, and has more efficacy data. Nifurtimox is an alternative option.[2]

Both drugs are contraindicated in pregnancy and severe hepatic/renal impairment. A negative pregnancy test is required before starting treatment in women of childbearing potential.

Adverse effects are more frequent and severe with increasing age and include: allergic dermatitis, peripheral neuropathy, weight loss, insomnia, leukopenia (benznidazole); polyneuropathy, nausea/vomiting, headache, dizziness/vertigo, and weight loss (nifurtimox). A complete blood count is recommended 21 days after starting treatment with benznidazole to monitor for leukopenia.[2] CDC: Chagas disease: antiparasitic treatment Opens in new window 

Availability varies across countries. In the US, benznidazole is approved in children 2 to 12 years of age and is available here: Exeltis: benznidazole tablets Opens in new window Nifurtimox is now also commercially available in the US, and no longer needs to be obtained from the Centers for Disease Control and Prevention.[172] In other countries, the drugs are available from local health regulatory agencies such as the World Health Organization.[173]

Treatment course: 60 days (benznidazole); 60-90 days (nifurtimox).

Primary options

benznidazole: children <2 years of age: consult specialist for guidance on dose; children 2-12 years of age: 5-8 mg/kg/day orally given in 2 divided doses; children >12 years of age and adults: 5-7 mg/kg/day orally given in 2 divided doses

Secondary options

nifurtimox: children <1 year of age: consult specialist for guidance on dose; children 1-10 years of age: 15-20 mg/kg/day orally given in 3-4 divided doses; children 11-16 years of age: 12.5 to 15 mg/kg/day orally given in 3-4 divided doses; children ≥17 years of age and adults: 8-10 mg/kg/day orally given in 3-4 divided doses

Plus – supportive therapy

Back
ACUTE
|
acute infection
|
nonpregnant without severe renal/hepatic insufficiency
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

Supportive treatment should be targeted at the presenting symptoms.

Cardiac manifestations may be treated with weight control; salt intake control; water intake control; alcohol avoidance; influenza/pneumococcal vaccination; and limiting sporting activity.

Consider – medical management of cardiac disease and/or surgical intervention

Back
ACUTE
|
acute infection
|
nonpregnant without severe renal/hepatic insufficiency
Consider – 

medical management of cardiac disease and/or surgical intervention

Treatment recommended for SOME patients in selected patient group

Patients with cardiopathy may require pacemaker placement for atrial and ventricular rhythm disturbances; ablation procedures for tachyarrhythmias; implanted defibrillators; or resection of left ventricular apical aneurysms (not defined).[4]​​[26]​​[143][144][176][190]​ ​Drugs such as ACE inhibitors or angiotensin-II receptor antagonists, beta-blockers, aldosterone receptor antagonists, diuretics, digoxin, anticoagulants, antiplatelet agents, and amiodarone are recommended depending on the presentation (e.g., heart failure, arrhythmias, stroke).[2]

1st line – supportive therapy

Back
ACUTE
|
acute infection
|
pregnant or with severe renal/hepatic insufficiency
1st line – 

supportive therapy

Supportive treatment should be targeted at the presenting symptoms.

Cardiac manifestations may be treated with weight control; salt intake control; water intake control; alcohol avoidance; influenza/pneumococcal vaccination; and limiting sporting activity.

Breast-feeding is not recommended in mothers in the acute phase of the disease.[171]

Consider – medical management of cardiac disease and/or surgical intervention

Back
ACUTE
|
acute infection
|
pregnant or with severe renal/hepatic insufficiency
Consider – 

medical management of cardiac disease and/or surgical intervention

Treatment recommended for SOME patients in selected patient group

Patients with cardiopathy may require pacemaker placement for atrial and ventricular rhythm disturbances; ablation procedures for tachyarrhythmias; implanted defibrillators; or resection of left ventricular apical aneurysms.[4]​​[26]​​[143][144][176][190]​​ Drugs such as ACE inhibitors or angiotensin-II receptor antagonists, beta-blockers, aldosterone receptor antagonists, diuretics, digoxin, anticoagulants, antiplatelet agents, and amiodarone are recommended depending on the presentation (e.g., heart failure, arrhythmias, stroke).[2]

reactivated disease

1st line – antiparasitic treatment

Back
ACUTE
|
reactivated disease
|
nonpregnant without severe renal/hepatic insufficiency
1st line – 

antiparasitic treatment

Recommended in all patients with disease reactivation.[2] Reactivation risk varies considerably, depending on the degree of immunosuppression.[95][103][197]

Benznidazole is the recommended first-line treatment as it is more widely available, is better tolerated, and has more efficacy data. Nifurtimox is an alternative option.[2]

Both drugs are contraindicated in pregnancy and severe hepatic/renal impairment. A negative pregnancy test is required before starting treatment in women of childbearing potential.

Adverse effects are more frequent and severe with increasing age and include: allergic dermatitis, peripheral neuropathy, weight loss, insomnia, leukopenia (benznidazole); polyneuropathy, nausea/vomiting, headache, dizziness/vertigo, and weight loss (nifurtimox). A complete blood count is recommended 21 days after starting treatment with benznidazole to monitor for leukopenia.[2] CDC: Chagas disease: antiparasitic treatment Opens in new window 

Availability varies across countries. In the US, benznidazole is approved in children 2 to 12 years of age and is available here: Exeltis: benznidazole tablets Opens in new window Nifurtimox is now also commercially available in the US, and no longer needs to be obtained from the Centers for Disease Control and Prevention.[172] In other countries, the drugs are available from local health regulatory agencies such as the World Health Organization.[173]

Treatment course: 60 days (benznidazole); 60-90 days (nifurtimox).

Primary options

benznidazole: children <2 years of age: consult specialist for guidance on dose; children 2-12 years of age: 5-8 mg/kg/day orally given in 2 divided doses; children >12 years of age and adults: 5-7 mg/kg/day orally given in 2 divided doses

Secondary options

nifurtimox: children <1 year of age: consult specialist for guidance on dose; children 1-10 years of age: 15-20 mg/kg/day orally given in 3-4 divided doses; children 11-16 years of age: 12.5 to 15 mg/kg/day orally given in 3-4 divided doses; children ≥17 years of age and adults: 8-10 mg/kg/day orally given in 3-4 divided doses

Plus – supportive therapy

Back
ACUTE
|
reactivated disease
|
nonpregnant without severe renal/hepatic insufficiency
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

Supportive treatment should be targeted at the presenting symptoms.

Cardiac manifestations: weight control; salt intake control; water intake control; alcohol avoidance; influenza/pneumococcal vaccination; and limiting sporting activity.

Esophageal manifestations: advise to chew food well and consume liquid or semi-solid food; avoid eating food or taking tablets before sleep.

Colonic manifestations: dietary advice (avoid constipating foods, drink plenty of water, consume high-fiber foods to speed up transit times); advise to defecate regularly and use osmotic laxatives, mineral oil, or enemas if necessary; advise avoidance of constipating medications if possible.

Consider – medical management of cardiac disease and/or surgical intervention

Back
ACUTE
|
reactivated disease
|
nonpregnant without severe renal/hepatic insufficiency
Consider – 

medical management of cardiac disease and/or surgical intervention

Treatment recommended for SOME patients in selected patient group

Patients with cardiopathy may require pacemaker placement for atrial and ventricular rhythm disturbances; ablation procedures for tachyarrhythmias; implanted defibrillators; or resection of left ventricular apical aneurysms.[4]​​[26]​​[143][144][176][190]​ Drugs such as ACE inhibitors or angiotensin-II receptor antagonists, beta-blockers, aldosterone receptor antagonists, diuretics, digoxin, anticoagulants, antiplatelet agents, and amiodarone are recommended depending on the presentation (e.g., heart failure, arrhythmias, stroke).[2]

Patients with megaesophagus may require esophagocardiomyectomy of the anterior gastroesophageal junction (combined with valvuloplasty), to reduce reflux in cases with no response to esophageal dilation; laparoscopic myotomy, to manage severe megaesophagus; or partial esophageal resection with reconstruction by esophagogastroplasty, in severe cases.[4]​​[26][158]

Patients with megacolon may require the Duhamel-Haddad operation, and patients with sigmoid volvulus may require anterior sigmoidostomy with resection of the necrosed segment.[4]​​[26]

1st line – supportive therapy

Back
ACUTE
|
reactivated disease
|
pregnant or with severe renal/hepatic insufficiency
1st line – 

supportive therapy

Supportive treatment should be targeted at the presenting symptoms.

Cardiac manifestations: weight control; salt intake control; water intake control; alcohol avoidance; influenza/pneumococcal vaccination; and limiting sporting activity.

Esophageal manifestations: advise to chew food well and consume liquid or semi-solid food; avoid eating food or taking tablets before sleep.

Colonic manifestations: dietary advice (avoid constipating foods, drink plenty of water, consume high-fiber foods to speed up transit times); advise to defecate regularly and use osmotic laxatives, mineral oil, or enemas if necessary; advise avoidance of constipating medications if possible.

Pregnancy is rare in this group of patients. Clinical monitoring is indicated, and maternal immune status should be improved. High levels of parasitemia, as found in HIV-infected patients, may favor higher rates of vertical transmission of Chagas disease. Ideally, children born to HIV-infected mothers should not be breast-fed. Antiparasitic drugs should be withheld until after the birth, or until the renal/hepatic impairment has improved.

Consider – medical management of cardiac disease and/or surgical intervention

Back
ACUTE
|
reactivated disease
|
pregnant or with severe renal/hepatic insufficiency
Consider – 

medical management of cardiac disease and/or surgical intervention

Treatment recommended for SOME patients in selected patient group

Patients with cardiopathy may require pacemaker placement for atrial and ventricular rhythm disturbances; ablation procedures for tachyarrhythmias; implanted defibrillators; or resection of left ventricular apical aneurysms (not defined).[4]​​[26]​​[143][144][176][190]​ Drugs such as ACE inhibitors or angiotensin-II receptor antagonists, beta-blockers, aldosterone receptor antagonists, diuretics, digoxin, anticoagulants, antiplatelet agents, and amiodarone are recommended depending on the presentation (e.g., heart failure, arrhythmias, stroke).[2] 

Patients with megaesophagus may require esophagocardiomyectomy of the anterior gastroesophageal junction (combined with valvuloplasty), to reduce reflux in cases with no response to esophageal dilation; laparoscopic myotomy, to manage severe megaesophagus; or partial esophageal resection with reconstruction by esophagogastroplasty, in severe cases.[4]​​[26][158]

Patients with megacolon may require the Duhamel-Haddad operation, and patients with sigmoid volvulus may require anterior sigmoidostomy with resection of the necrosed segment.[4]​​[26]

ONGOING

chronic infection: indeterminate disease or mild to moderate symptoms: children

1st line – antiparasitic treatment

Back
ONGOING
|
chronic infection: indeterminate disease or mild to moderate symptoms: children
1st line – 

antiparasitic treatment

Treatment is recommended all pediatric patients <18 years of age.[2]​[166][176]​​​​

Benznidazole is the recommended first-line treatment as it is more widely available, is better tolerated, and has more efficacy data. Nifurtimox is an alternative option.[2]

Both drugs are contraindicated in pregnancy and severe hepatic/renal impairment. A negative pregnancy test is required before starting treatment in women of childbearing potential.

Adverse effects are more frequent and severe with increasing age and include: allergic dermatitis, peripheral neuropathy, weight loss, insomnia, leukopenia (benznidazole); polyneuropathy, nausea/vomiting, headache, dizziness/vertigo, and weight loss (nifurtimox). A complete blood count is recommended 21 days after starting treatment with benznidazole to monitor for leukopenia.[2] CDC: Chagas disease: antiparasitic treatment Opens in new window 

Availability varies across countries. In the US, benznidazole is approved in children 2 to 12 years of age and is available here: Exeltis: benznidazole tablets Opens in new window Nifurtimox is now also commercially available in the US, and no longer needs to be obtained from the Centers for Disease Control and Prevention.[172] In other countries, the drugs are available from local health regulatory agencies such as the World Health Organization.[173]

Treatment course: 60 days (benznidazole); 60-90 days (nifurtimox).

Primary options

benznidazole: children <2 years of age: consult specialist for guidance on dose; children 2-12 years of age: 5-8 mg/kg/day orally given in 2 divided doses; children >12 years of age: 5-7 mg/kg/day orally given in 2 divided doses

Secondary options

nifurtimox: children <1 year of age: consult specialist for guidance on dose; children 1-10 years of age: 15-20 mg/kg/day orally given in 3-4 divided doses; children 11-16 years of age: 12.5 to 15 mg/kg/day orally given in 3-4 divided doses; children ≥17 years of age: 8-10 mg/kg/day orally given in 3-4 divided doses

Plus – supportive therapy

Back
ONGOING
|
chronic infection: indeterminate disease or mild to moderate symptoms: children
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

Supportive treatment should be targeted at the presenting symptoms.

Cardiac manifestations: weight control; salt intake control; water intake control; alcohol avoidance; influenza/pneumococcal vaccination; and limiting sporting activity.

Esophageal manifestations: advice to chew food well and consume liquid or semi-solid food; avoid food consumption or taking tablets before sleep.

Colonic manifestations: dietary advice (avoid constipating foods, drink plenty of water, consume high-fiber foods to speed up transit times); advise to defecate regularly and use osmotic laxatives, mineral oil, or enemas if necessary; advise avoidance of constipating medications if possible.

chronic infection: indeterminate disease or mild to moderate symptoms: adults

1st line – antiparasitic treatment

Back
ONGOING
|
chronic infection: indeterminate disease or mild to moderate symptoms: adults
1st line – 

antiparasitic treatment

Treatment may be considered in patients >18 years of age with indeterminate disease (i.e., positive serology with no evidence of end-organ damage), mild-to-moderate cardiomyopathy (i.e., without congestive cardiac failure), and gastrointestinal disease.[2][34][177][178][179]

The Centers for Disease Control and Prevention (CDC) strongly recommend treatment in adults ≤50 years of age who do not have advanced Chagas cardiomyopathy. Due to the increased risk of drug toxicity, the CDC only recommend treatment in adults >50 years after weighing the risks and benefits of treatment, taking into consideration factors such as age, clinical status, overall health, and patient preference. CDC: Chagas disease: antiparasitic treatment Opens in new window

Benznidazole is the recommended first-line treatment as it is more widely available, is better tolerated, and has more efficacy data. Nifurtimox is an alternative option.[2]

Both drugs are contraindicated in pregnancy and severe hepatic/renal impairment. A negative pregnancy test is required before starting treatment in women of childbearing potential.

Adverse effects are more frequent and severe with increasing age and include: allergic dermatitis, peripheral neuropathy, weight loss, insomnia, leukopenia (benznidazole); polyneuropathy, nausea/vomiting, headache, dizziness/vertigo, and weight loss (nifurtimox). A complete blood count is recommended 21 days after starting treatment with benznidazole to monitor for leukopenia.[2] CDC: Chagas disease: antiparasitic treatment Opens in new window 

Availability varies across countries. In the US, benznidazole is available here: Exeltis: benznidazole tablets Opens in new window Nifurtimox is now also commercially available in the US, and no longer needs to be obtained from the Centers for Disease Control and Prevention.[172] In other countries, the drugs are available from local health regulatory agencies such as the World Health Organization.[173]

Treatment course: 60 days (benznidazole); 60-90 days (nifurtimox).

Primary options

benznidazole: adults: 5-7 mg/kg/day orally given in 2 divided doses

OR

nifurtimox: adults: 8-10 mg/kg/day orally given in 3-4 divided doses

Plus – supportive therapy

Back
ONGOING
|
chronic infection: indeterminate disease or mild to moderate symptoms: adults
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

Supportive treatment should be targeted at the presenting symptoms.

Cardiac manifestations: weight control; salt intake control; water intake control; alcohol avoidance; influenza/pneumococcal vaccination; and limiting sporting activity. Individualized cardiovascular rehabilitation based on simple, supervised aerobic training can be safely performed in patients with chronic Chagas disease.[185][186][187][188]

Esophageal manifestations: advise to chew food well and consume liquid or semi-solid food; avoid eating food or taking tablets before sleep.

Colonic manifestations: dietary advice (avoid constipating foods, drink plenty of water, consume high-fiber foods to speed up transit times); advise to defecate regularly and use osmotic laxatives, mineral oil, or enemas if necessary; advise avoidance of constipating medications if possible.

Consider – medical management of cardiac disease and/or surgical intervention

Back
ONGOING
|
chronic infection: indeterminate disease or mild to moderate symptoms: adults
Consider – 

medical management of cardiac disease and/or surgical intervention

Treatment recommended for SOME patients in selected patient group

Patients with cardiopathy may require pacemaker placement for atrial and ventricular rhythm disturbances; ablation procedures for tachyarrhythmias; implanted defibrillators; or heart transplant.[4]​​[26]​​[143][144][176][190]​ Drugs such as ACE inhibitors or angiotensin-II receptor antagonists, beta-blockers, aldosterone receptor antagonists, diuretics, digoxin, anticoagulants, antiplatelet agents, and amiodarone are recommended depending on the presentation (e.g., heart failure, arrhythmias, stroke).[2] 

Patients with megaesophagus may require esophagocardiomyectomy of the anterior gastroesophageal junction (combined with valvuloplasty), to reduce reflux in cases with no response to esophageal dilation; laparoscopic myotomy, to manage severe megaesophagus; or partial esophageal resection with reconstruction by esophagogastroplasty, in severe cases.[4]​​[26][158]

Patients with megacolon may require the Duhamel-Haddad operation, and patients with sigmoid volvulus may require anterior sigmoidostomy with resection of the necrosed segment.[4]​​[26]

chronic infection: advanced disease: children and adults

1st line – supportive therapy

Back
ONGOING
|
chronic infection: advanced disease: children and adults
1st line – 

supportive therapy

Antiparasitic treatment is not indicated in cases of advanced disease, such as Chagasic cardiomyopathy with congestive heart failure (Kuschnir grade III), megaesophagus, or megacolon.[34] The focus is on supportive therapy, since regression of inflammatory and fibrotic lesions, as observed in experimental studies, has not yet been confirmed clinically.[13][34][164]

Supportive treatment should be targeted at the presenting symptoms.

Cardiac manifestations: weight control; salt intake control; water intake control; alcohol avoidance; influenza/pneumococcal vaccination; and limiting sporting activity. Individualized cardiovascular rehabilitation based on simple, supervised aerobic training can be safely performed in patients with chronic Chagas disease.[185][186][187][188]

Esophageal manifestations: advice to chew food well and consume liquid or semi-solid food; avoidance of food consumption or taking tablets before sleep.

Colonic manifestations: dietary advice (avoid constipating foods, drink plenty of water, consume high-fiber foods to speed up transit times); advise to defecate regularly and use osmotic laxatives, mineral oil, or enemas if necessary; advise avoidance of constipating medications if possible.

Consider – medical management of cardiac disease and/or surgical intervention

Back
ONGOING
|
chronic infection: advanced disease: children and adults
Consider – 

medical management of cardiac disease and/or surgical intervention

Treatment recommended for SOME patients in selected patient group

Patients with cardiopathy may require pacemaker placement for atrial and ventricular rhythm disturbances; ablation procedures for tachyarrhythmias; implanted defibrillators; or heart transplant.[4]​​[26]​​[143][144][176][190]​ Drugs such as ACE inhibitors or angiotensin-II receptor antagonists, beta-blockers, aldosterone receptor antagonists, diuretics, digoxin, anticoagulants, antiplatelet agents, and amiodarone are recommended depending on the presentation (e.g., heart failure, arrhythmias, stroke).[2] 

Patients with megaesophagus may require esophagocardiomyectomy of the anterior gastroesophageal junction (combined with valvuloplasty), to reduce reflux in cases with no response to esophageal dilation; laparoscopic myotomy, to manage severe megaesophagus; or partial esophageal resection with reconstruction by esophagogastroplasty, in severe cases.[4]​​[26][158]

Patients with megacolon may require the Duhamel-Haddad operation, and patients with sigmoid volvulus may require anterior sigmoidostomy with resection of the necrosed segment.[4]​​[26]

end-stage organ failure

1st line – organ transplantation

Back
ONGOING
|
end-stage organ failure
1st line – 

organ transplantation

Patients with Chagasic end-stage organ failure may require organ transplantation. In these situations, the serologic status of donor and receiver should be checked, as the risk of infection transmission and Chagas reactivation needs to be considered for both.[13][97][165][176][196] The surgical transplant team will be able to decide which parties require antiparasitic treatment.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer