Treatment of Strongyloidiasis in the United States
The recommended treatment for Strongyloides stercoralis infection in the United States is ivermectin at a dose of 200 μg/kg orally for 2 consecutive days, which provides the highest cure rate with excellent tolerability. 1, 2
First-Line Treatment
- Ivermectin is FDA-approved for strongyloidiasis of the intestinal tract with cure rates of 64-100% following a single 200 μg/kg dose 2
- The standard dosing regimen is 200 μg/kg orally for 2 consecutive days 1
- Efficacy studies show ivermectin is significantly more effective than albendazole, with cure rates of 83-96.8% for ivermectin compared to only 38-63.3% for albendazole 3, 4, 5
Special Populations
- For immunocompromised patients, an extended regimen of ivermectin 200 μg/kg on days 1,2,15, and 16 is recommended to prevent hyperinfection syndrome 1
- Patients receiving corticosteroids or other immunosuppressive therapy should be screened and treated for Strongyloides before initiating immunosuppression 6
- In cases of hyperinfection syndrome with small bowel obstruction where oral administration is not possible, subcutaneous ivermectin (veterinary formulation) has been used successfully in case reports 7
Follow-Up and Monitoring
- At least three stool examinations should be conducted over three months following treatment to ensure eradication 2
- If larvae recur in stool samples, retreatment with ivermectin is indicated 2
- Concentration techniques (such as using a Baermann apparatus) should be employed when performing stool examinations, as the number of Strongyloides larvae per gram of feces may be very low 2
Alternative Treatment Options
- Albendazole 400 mg daily for 3 days is an alternative but less effective option, with cure rates of only 38-63% compared to ivermectin's 77-100% 1, 5
- A Cochrane review confirmed that ivermectin results in more cures than albendazole and is at least as well tolerated 5
Prevention of Hyperinfection Syndrome
- Screen for Strongyloides stercoralis in patients likely to require prolonged corticosteroids 6
- Treat confirmed or suspected Strongyloides infection before initiating corticosteroid therapy to prevent potentially fatal hyperinfection syndrome 1, 8
- Hyperinfection syndrome carries a high mortality risk, particularly in immunocompromised patients 7, 8
Common Side Effects
- Dizziness, nausea, and disorientation are commonly reported with ivermectin treatment 5
- Serious adverse events are rare with standard dosing of ivermectin 3, 5
Clinical Pearls
- Strongyloidiasis can persist for decades due to the parasite's unique autoinfection cycle 8
- Diagnosis is challenging due to low parasite load and intermittent larval shedding, making serological testing often more sensitive than stool examination 9
- Consider empiric treatment for patients from endemic areas who will be receiving immunosuppressive therapy, even without confirmed diagnosis 6, 1