Optimal Management of Intestinal Helminthiasis (Stomach Worms)
First-Line Treatment
Albendazole 400 mg orally as a single dose is the recommended first-line treatment for most intestinal worm infections, including hookworm, roundworm, and pinworm. 1
This recommendation comes from the American Society of Tropical Medicine and Hygiene and represents the standard approach for uncomplicated intestinal helminthiasis. 1
Treatment by Specific Helminth Type
The optimal regimen varies based on the specific parasite identified:
Hookworm Infections
- Standard treatment: Albendazole 400 mg orally with a repeat dose in 2 weeks 2
- Alternative CDC regimen: Albendazole 400 mg PO daily for 3 days 1
- For severe hookworm disease with anemia: Add prednisolone 40-60 mg once daily per WHO recommendations 1
Roundworm (Ascaris) and Pinworm (Enterobius)
- Single dose: Albendazole 400 mg orally 1
- For pinworm specifically: Treat all household contacts simultaneously due to high contagiousness 1
Whipworm (Trichuris)
- Combination therapy: Mebendazole 100 mg PO twice daily PLUS ivermectin 200 μg/kg once daily for 3 days 1
- This dual approach is recommended by the Infectious Diseases Society of America 1
Threadworm/Strongyloides
- Extended treatment: Albendazole 400 mg PO twice daily for 21 days 1
- Critical monitoring: Liver function tests and complete blood count throughout treatment 1
- Important note: Ivermectin cure rates for strongyloidiasis range from 64-100% with single-dose therapy (200 mcg/kg), compared to 92-83% for albendazole 3
Empirical Treatment Strategy
For patients from endemic areas with high pretest probability but negative stool tests:
Give albendazole 400 mg PLUS ivermectin 200 μg/kg as a single combined dose. 1, 2
This approach is particularly warranted for:
- Long-term residence (≥6 years) in endemic areas 2
- Clinical suspicion with negative diagnostic testing 2
- Travelers returning from high-risk areas who walked barefoot or had soil contact 2
The rationale is that standard stool microscopy has poor sensitivity, identifying pathogens in only 1.4% of samples in some studies, leading to high false-negative rates. 2
Critical Safety Precautions
Before Ivermectin Administration
Screen for Loa loa infection before giving ivermectin in patients from Central/West Africa to prevent severe encephalopathy. 1, 3
This is a critical safety measure recommended by both the CDC and WHO, as ivermectin can cause fatal reactions in patients with loiasis. 1, 3
Monitoring Requirements
- For albendazole >14 days: Monitor for hepatotoxicity and leukopenia 4
- For strongyloides treatment: Liver function tests and CBC throughout the 21-day course 1
- Post-treatment for strongyloides: At least three stool examinations over three months to ensure eradication, as recrudescence can occur up to 106 days post-treatment 3
Special Populations Requiring Expert Consultation
- Immunocompromised patients (may require repeated courses or suppressive monthly therapy) 3
- Children aged 12-24 months 1
- Severe disease requiring intensive care 1
- Pregnant women (albendazole is Pregnancy Category C and should not be used) 3
Prevention of Reinfection
To prevent reinfection after successful treatment:
- Hand hygiene with soap before eating and after defecation 1
- Wearing shoes in endemic areas 1, 2
- Treating household contacts for highly contagious infections like pinworm 1
Common Pitfalls to Avoid
Inadequate follow-up for strongyloides: Use concentration techniques (Baermann apparatus) for stool examinations, as larval counts may be very low 3
Single stool examination: Multiple stool samples collected on different days increase diagnostic yield due to intermittent egg shedding 2
Ignoring geographic risk factors: Patients with prolonged endemic area exposure warrant empiric treatment even with negative testing 2
Forgetting Loa loa screening: This critical step prevents potentially fatal complications from ivermectin 1, 3
Inadequate treatment duration for whipworm: Single-dose albendazole has only 27-60% cure rates for Trichuris; combination therapy with mebendazole plus ivermectin is superior 1