Treatment of Strongyloides stercoralis Infection
Ivermectin 200 μg/kg orally for 2 consecutive days is the recommended treatment for uncomplicated strongyloidiasis, providing cure rates of 77-100% with excellent tolerability. 1, 2
Standard Treatment Regimen
- Administer ivermectin 200 μg/kg orally on 2 consecutive days for uncomplicated intestinal strongyloidiasis 1, 2
- Take tablets on an empty stomach with water to optimize absorption 2
- This 2-day regimen achieves 100% cure rates compared to 77% with single-dose therapy 3
- The FDA-approved single dose (200 μg/kg once) is effective but the 2-day regimen shows superior efficacy in clinical practice 2, 4
Immunocompromised Patients
For immunocompromised patients, use ivermectin 200 μg/kg on days 1,2,15, and 16 to prevent treatment failure and hyperinfection syndrome 1
- This includes patients with HIV, hematologic malignancies, solid tumors, diabetes mellitus, systemic lupus erythematosus, or those receiving corticosteroids 4, 2
- Multiple treatment courses may be required, and cure may not be achievable in severely immunosuppressed patients 2
- Consider suppressive therapy (once monthly) for patients who cannot achieve parasitological cure 2
Critical Pre-Treatment Screening
Screen all patients from endemic areas for strongyloidiasis BEFORE initiating corticosteroids or immunosuppressive therapy to prevent potentially fatal hyperinfection syndrome 1, 5
- Corticosteroid initiation without treating strongyloidiasis can precipitate hyperinfection with gastrointestinal bleeding, pneumonia, sepsis, or meningitis 1
- Consider empiric treatment for high-risk patients from endemic areas even without confirmed diagnosis if immunosuppression is planned 1, 6
- Patients with Loa loa co-infection require special consideration due to risk of encephalopathy; assess exposure to West/Central Africa 2
Alternative Treatment
- Albendazole 400 mg daily for 3 days is a less effective alternative with cure rates of only 38-63% 1, 7
- Reserve albendazole for situations where ivermectin is contraindicated or unavailable 8, 7
Post-Treatment Monitoring
- Perform follow-up stool examinations to verify parasitological cure 2
- Monitor for persistent eosinophilia, which indicates treatment failure in 77% of cases 3
- Re-treat patients who fail initial therapy with repeat courses of ivermectin 2, 3
Safety Considerations
- Ivermectin is generally well-tolerated with minimal adverse effects (dizziness, dyspepsia in <10% of patients) 3
- Avoid use during pregnancy (Category C) as teratogenicity has been demonstrated in animal studies 2
- Use caution in elderly patients and those with hepatic or renal dysfunction 2
- Monitor INR if co-administered with warfarin due to rare reports of increased INR 2