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Quinacrine treatment of nitroimidazole-refractory giardiasis. BACKGROUND: Limited evidence exists on the efficacy and tolerability of quinacrine for nitroimidazole-refractory giardiasis. METHODS: Nitroimidazole-refractory giardiasis cases, defined as microbiologically (microscopy and/or PCR) confirmed treatment failure after two courses, during 2008-2020, were retrospectively identified. RESULTS: Of 87 patients, 54 (62%) had visited India. Quinacrine was used in 54 (62%); 51 received monotherapy and three combined with metronidazole. Only three had positive stool samples with persisting symptoms after quinacrine treatment (94% parasitological efficacy), and all were cured after a second treatment. One (1.9%) had mild adverse effects recorded. CONCLUSIONS: Quinacrine is an effective treatment for nitroimidazole-refractory giardiasis with good tolerability.