What is your preferred regimen for treating recalcitrant and recurrent macula-threatening ocular toxoplasmosis?

Treatment options for ocular toxoplasmosis include:

1. Trimethoprim/sulfamethoxazole (Bactrim)
2. Azithromycin
3. Pyrimethamine + sulfadiazine + folinic acid
4. Atovaquone
5. Oral clindamycin
6. Intravitreal clindamycin

I usually start with Bactrim DS PO BID. If a patient is sulfa allergic or pregnant, I start with azithromycin (500 mg on day 1 followed by 250 mg PO daily). If there is a fovea-threatening lesion, I will also inject clindamycin 2 mg/0.1 ml and repeat this weekly if needed.

If a patient has recurrent disease after cessation of antibiotics, I will restart the same antibiotic regimen used to originally treat the disease, and once the chorioretinitis is completely inactive, I will continue antibiotics on a maintenance regimen of Bactrim DS or azit...