Ascariasis

Anthelminthic therapy — Anthelminthic therapy helps reduce morbidity associated with Ascaris
infection but may not prevent frequent reinfection [71,72]. Several agents have activity against
A. lumbricoides as discussed in the following sections. These agents are active against adult
worms but not against larvae.

Issues related to mass drug administration for control of ascariasis are discussed separately. (See
"Mass drug administration for control of parasitic infections".)

First-line agents — The mainstays of treatment for ascariasis (caused by A. suum or A.

lumbricoides) in nonpregnant adults and children are the benzimidazoles: albendazole (400 mg
orally single dose on empty stomach) or mebendazole (500 mg orally single dose or 100 mg
orally twice daily for three days). Adverse effects of the benzimidazoles include transient
gastrointestinal discomfort, headache, and, rarely, leukopenia. (See "Anthelminthic therapies".)

A single dose of albendazole is effective in achieving cure in almost 100 percent of ascariasis
cases [73-75]. Both mebendazole regimens (three day and single dose) are approximately 95
percent effective. A meta-analysis including 20 randomized trials demonstrated high cure rates
with single doses of albendazole and mebendazole [76]. Single-dose albendazole is not sufficient
for treatment of concomitant hookworm or Trichuris infection [77].

In a systematic review and network meta-analysis, average cure rates for treatment of A.
lumbricoides with albendazole, mebendazole, and pyrantel pamoate were 96, 96, and 93 percent,
respectively [78]. The highest estimated egg reduction rate was for albendazole (99 percent),
followed by mebendazole and pyrantel pamoate (98 and 94 percent, respectively). There were no
significant differences among the treatments.

Pregnant women should be treated with pyrantel pamoate, given potential teratogenic effects
associated with benzimidazoles in animals [76]. Pyrantel pamoate (11 mg/kg up to a maximum
of 1 g) is administered as a single dose. The efficacy varies with worm load; single-dose therapy
is approximately 90 percent effective in eradicating adult worms [79]. Adverse effects of
pyrantel pamoate include gastrointestinal disturbances, headaches, rash, and fever.

Alternative agents — Alternative agents for treatment of ascariasis include ivermectin,

nitazoxanide, piperazine citrate, and levamisole. (See "Anthelminthic therapies".)

●Ivermectin – Ivermectin causes paralysis of adult worms. In one study comparing ivermectin
(200 mcg/kg single dose) and albendazole (400 mg single dose), cure rates were similar (78
versus 70 percent) [80].

●Nitazoxanide – The efficacy of nitazoxanide varies according to egg burden [81-83]. In patients
with light infection, cure rates of 100 percent have been observed; in patients with heavy egg
burdens (>10,000 eggs/g stool), cure rates of 50 to 80 percent can be achieved [83]. In a
randomized trial among Peruvian children, comparable cure rates with nitazoxanide (three-day
course) and albendazole (single dose) were observed (89 percent versus 91 percent) [84].
●Piperazine citrate – Piperazine citrate (50 to 75 mg/kg once daily up to a maximum of 3.5 g for
two days) was a frequently used treatment regimen; it has been withdrawn from the market in
many regions because other available alternatives are less toxic and more efficacious. However,
it may still be useful for cases in which intestinal or biliary obstruction is suspected since the
drug paralyzes worms, aiding expulsion.

Follow-up — Given the high cure rate with anthelminthic therapy, routine repeat stool testing is
not essential; it may be pursued two to three months following treatment for patients in
nonendemic areas to ensure infection has resolved. Detection of eggs at follow-up stool
examination suggests inadequate elimination of adult worms or reinfection. In such cases,
retreatment with the same regimen is warranted. (See 'Clinical approach' above.)

Given the propensity of ascariasis to cluster in households, detection of persistent or repeat

infection should prompt stool evaluation of other household members. If infection is detected
among these individuals, all may be treated simultaneously with a benzimidazole (albendazole or
mebendazole). (See 'Clinical approach' above.)

In endemic areas, reinfection occurs frequently; in some areas, more than 80 percent of
individuals become reinfected within six months. Intermittent mass drug therapy for such
circumstances is discussed separately. (See "Mass drug administration for control of parasitic
infections".)

Hookworm

THERAPY — Iron replacement alone can lead to restoration of a normal hemoglobin level in
individuals with hookworm infection, but anemia recurs unless anthelminthic therapy is given.

Anthelminthic treatment of hookworm infection consists of albendazole (400 mg once on empty

stomach) [31,32]. Mebendazole is an acceptable alternative therapy; 100 mg twice daily for three
days is more effective than a single dose of 500 mg. In a randomized, controlled trial conducted
in China among 314 patients aged ≥5 years, single-dose albendazole had greater efficacy than
single-dose mebendazole (69 and 29 percent cure rates, respectively) [33]. Triple-dose therapy
had greater efficacy, with cure rates of 92 and 54 percent, respectively [33]. An alternative
therapy is pyrantel pamoate (11 mg/kg per day for three days, not to exceed 1 g/day) [31].
Ivermectin has poor efficacy against hookworm.

Therapy of hookworm infections in patients with marginal nutrition status has beneficial effects
on growth, exercise tolerance, and cognitive function [3]. Even in those without impaired
nutrition, anthelminthic therapies can improve hemoglobin levels [34].

Enterobiasis (pinworm)

Treatment — Treatment of enterobiasis consists of the following anthelminthic options:

●Albendazole (400 mg orally once on empty stomach; repeat in two weeks) or mebendazole
(100 mg orally once; repeat in two weeks) [16-19]. A single dose results in relatively high cure
rates, although a second dose repeated at two weeks achieves a cure rate close to 100 percent and
helps prevent recurrence due to reinfection [8,20]. (See 'Life cycle and transmission' above.)

●Pyrantel pamoate (11 mg/kg; maximum 1 g). It is the most frequently used medication in the
United States as it is cheap and available over the counter and also has an efficacy of close to
100 percent if two doses are given two weeks apart [19]. Adverse effects can include anorexia,
nausea, vomiting, abdominal cramps, diarrhea, neurotoxic effects, and transient increases in
hepatic enzymes.

Reinfection is common, despite effective therapy. Therefore, simultaneous treatment of the entire
household is warranted given high transmission rates among families. In addition, all bedding
and clothes should be washed. Hygienic measures, such as clipping of fingernails, frequent
handwashing, and baths, are also helpful for reducing reinfection and spread of infection.

Ivermectin has efficacy against E. vermicularis but is not generally used for this indication
[21,22]. In one study, two doses of ivermectin 200 mcg/kg given at an interval of 10 days
resulted in a cure of 100 percent for enterobiasis [23].

Piperazine is no longer used because of lower efficacy and increased toxicity compared with the
benzimidazoles.

Pregnancy — Treatment of enterobiasis in pregnant women should be reserved for patients with
significant symptoms. Pyrantel pamoate is favored over mebendazole or albendazole for
treatment of symptomatic enterobiasis in pregnant women [24,25].

In one study of 192 pregnant women exposed to mebendazole during pregnancy (72 percent
during the first trimester), no increase in major malformations was observed compared with
matched controls, although there were more elective terminations in the group receiving
mebendazole [26].

TRICHURIASIS (WHIPWORM)

Treatment

Overview — Treatment of trichuriasis consists of anthelminthic therapy with mebendazole (500

mg once daily for three days or 100 mg orally twice daily for three days; 70 to >90 percent cure)
[8,35] or albendazole (400 mg orally on empty stomach once daily for three days; 80 percent
cure) [36]. Albendazole should be considered second-line treatment as its efficacy is lower
[37,38], although albendazole may be used if coinfection with hookworm has not been excluded.
A study showed cure rates with a single 400 mg dose of albendazole of 2.6 percent with egg-
reduction rates of 45 percent, compared with 11.8 and 75 percent, respectively, for a single 500
mg dose of mebendazole [37]. For patients with heavy infection (at least 1000 Trichuris eggs/g
feces), treatment regimens of five to seven days may be warranted [39].
Oxantel pamoate has been evaluated for treatment of trichuriasis; data are limited. One study
among children in Tanzania noted reasonable efficacy and tolerability with optimum therapeutic
dose range of 15 to 30 mg/kg (15 mg/kg: 49 percent cure and 97 percent egg reduction rate; 30
mg/kg: 59 percent cure rate and 99 percent egg reduction rate) [40].

Albendazole plus oxantel pamoate (in regions where available) may be more efficacious than
mebendazole or albendazole alone [37,41]. One study including 450 children with trichuriasis
noted that treatment with oxantel pamoate (20 mg/kg single dose) and albendazole (400 mg
single dose) resulted in higher cure and egg reduction rates at 3 weeks and 18 weeks after
treatment than albendazole or mebendazole alone [37,42].

Ivermectin (200 mcg/kg once daily) has some activity against trichuriasis, though it is not as
effective as mebendazole or albendazole for individual therapy [21,22,43]. There are limited data
on nitazoxanide for treatment of trichuriasis [44].

Issues related to population-based treatment are discussed separately. (See "Mass drug
administration for control of parasitic infections".)

Pregnancy — Mebendazole and albendazole should be avoided during pregnancy, particularly

during the first trimester. The risks of administering treatment to pregnant women with
trichuriasis must be weighed against the risks of delaying treatment. Therapy for patients with
trichuriasis in the absence of significant symptoms can be deferred until after delivery.