What is the treatment for helminth infections?

Treatment of Helminth Infections

The recommended first-line treatments for helminth infections are albendazole 400 mg, mebendazole 500 mg, or ivermectin 200 μg/kg as single oral doses, with specific medication selection based on the helminth species involved. 1, 2, 3

General Treatment Principles

• For most intestinal helminths (roundworms, hookworms, whipworms), albendazole 400 mg or mebendazole 500 mg as a single dose is highly effective 1, 3, 4
• For strongyloidiasis, ivermectin 200 μg/kg is the preferred treatment due to its superior efficacy (93-97% cure rates versus 63% for albendazole) 1, 5
• For asymptomatic eosinophilia with negative stool microscopy, empirical treatment with albendazole 400 mg plus ivermectin 200 μg/kg is recommended to treat possible prepatent or undetected geohelminth infection 1
• Always exclude Loa loa in people who have traveled to endemic regions BEFORE treating with ivermectin to prevent severe adverse reactions 1

Treatment by Specific Helminth Type

Intestinal Nematodes

• Ascaris lumbricoides (roundworm):

  • Albendazole 400 mg or mebendazole 500 mg as a single dose (92-98% cure rate) 2, 3, 6
  • Alternative: Ivermectin 200 μg/kg as a single dose 1, 5

• Hookworm (Ancylostoma duodenale/Necator americanus):

  • Albendazole 400 mg as a single dose (preferred due to higher efficacy - 72% cure rate versus 32% for pyrantel pamoate) 7, 5
  • Alternative: Mebendazole 500 mg as a single dose (96% cure rate) 3

• Trichuris trichiura (whipworm):

  • Combination therapy with ivermectin and albendazole (38-80% cure rate) 5
  • Alternative: Mebendazole 500 mg as a single dose (68% cure rate) 3, 6

• Enterobius vermicularis (pinworm):

  • Albendazole 400 mg or mebendazole 500 mg as a single dose, with repeat dose in 2 weeks 8, 3
  • The repeat dose is essential to eradicate newly hatched worms 8

• Strongyloides stercoralis:

  • Ivermectin 200 μg/kg as a single dose (preferred treatment) 1, 5
  • For hyperinfection syndrome in immunocompromised patients, seek specialist advice 1

Tissue Nematodes

• Cutaneous larva migrans (Ancylostoma braziliense/caninum):

  • Ivermectin 200 μg/kg as a single dose or albendazole 400 mg daily for 3 days 1

• Onchocerciasis (Onchocerca volvulus):

  • Doxycycline 200 mg daily for 6 weeks plus ivermectin 200 μg/kg monthly for 3 months 1
  • Exclude loiasis prior to treatment and seek expert advice in loiasis co-infection 1

Cestodes (Tapeworms)

• Taenia saginata/T. solium (beef/pork tapeworm):

  • Praziquantel 10 mg/kg as a single dose 1
  • For T. solium, establish species when possible as intestinal infection may coexist with neurocysticercosis 1

• Hymenolepis nana (dwarf tapeworm):

  • Praziquantel 25 mg/kg as a single dose 1

Trematodes (Flukes)

• Schistosomiasis (Schistosoma spp.):
  • Praziquantel 40-60 mg/kg in divided doses 1
  • For acute schistosomiasis (Katayama syndrome), consider corticosteroids in addition to praziquantel 1

Diagnostic Approach

• Concentrated stool microscopy is the first-line diagnostic test for most intestinal helminths 1, 2
• For pinworm, perianal swab or adhesive tape test is preferred to fecal concentrate 1
• For strongyloidiasis, serology or specialized stool PCR may be needed due to intermittent larval shedding 1
• Multiple stool samples may be required to increase diagnostic yield due to intermittent egg shedding 7

Special Considerations

• For pregnant women, treatment should be deferred until after the first trimester except in cases where the benefit outweighs the risk 1
• In immunocompromised patients with strongyloidiasis, aggressive treatment is essential to prevent hyperinfection syndrome 1
• For helminth infections with neurological involvement (neurocysticercosis, cerebral schistosomiasis), corticosteroids should be administered with anthelmintic therapy 1
• Drug resistance is emerging in hookworms, Trichuris trichiura, possibly Ascaris lumbricoides, Wuchereria bancrofti, and Giardia sp. 9

Monitoring and Follow-up

• For patients receiving prolonged treatment (>14-28 days), monitor liver function tests and complete blood counts due to potential hepatotoxicity and myelosuppression 4, 9
• Consider repeat stool examination 2-3 weeks after treatment if symptoms persist 7
• For schistosomiasis, repeat treatment at 8 weeks to treat any residual worms once they have developed into adults 1