What is the recommended first‑line therapy for uncomplicated hookworm infection in otherwise healthy children or adults, and what alternatives are appropriate for pregnant patients or those with severe anemia or malnutrition?

Treatment for Hookworm Infection

The recommended first-line treatment for uncomplicated hookworm infection in otherwise healthy children and adults is albendazole 400 mg orally as a single dose, repeated in 2 weeks. 1

First-Line Therapy

• Albendazole 400 mg orally, repeated after 2 weeks, is the standard treatment for both Ancylostoma duodenale and Necator americanus hookworm infections in all age groups including children and adults. 1

• This regimen achieves cure rates of approximately 69-97% with single-dose therapy, and increases to 92% or higher with the two-dose regimen (repeated at 2 weeks). 2, 3, 4

• The same 400 mg dose applies uniformly to both adults and children, with no weight-based adjustment needed for the standard two-dose regimen. 1

Alternative Treatment Options

Mebendazole

• Mebendazole is less effective than albendazole for hookworm, with single-dose cure rates of only 29-61% compared to albendazole's 69-97%. 3, 5

• If mebendazole must be used, a triple-dose regimen (500 mg daily for 3 consecutive days) achieves better results with cure rates of 54%, though still inferior to albendazole. 3

Combination Therapy for Empiric Treatment

• For patients with suspected but undetected hookworm (e.g., prolonged endemic area exposure with negative stool tests, or eosinophilia without identified pathogen), empiric treatment with albendazole 400 mg plus ivermectin 200 mcg/kg as a single dose is recommended. 1

• This combination covers prepatent infections and other soil-transmitted helminths that may be missed by standard stool microscopy. 1

Special Populations

Pregnant Women

• Albendazole should be avoided during pregnancy, particularly in the first trimester, due to potential teratogenic effects. 1

• For pregnant women requiring treatment, delay therapy until after the first trimester if clinically feasible. 1

• If treatment cannot be delayed and severe anemia or malnutrition is present, the risk-benefit ratio must be carefully considered, as untreated hookworm can cause significant maternal and fetal morbidity through iron-deficiency anemia. 1

Patients with Severe Anemia or Malnutrition

• Iron supplementation is critical in hookworm-infected patients with severe anemia, as the anemia is primarily due to chronic blood loss rather than the infection itself. 1

• Albendazole 400 mg repeated in 2 weeks remains the appropriate antiparasitic therapy, but must be accompanied by aggressive iron repletion and nutritional support. 1

• In severely malnourished patients, consider delaying treatment until nutritional status improves if the patient is stable, as anthelmintic therapy can occasionally precipitate clinical deterioration in severely compromised hosts. 1

Young Children

• For children aged 12-24 months with suspected hookworm infection, expert consultation is recommended before treatment. 1

• Children over 24 months receive the standard adult dose of albendazole 400 mg repeated in 2 weeks. 1

Monitoring and Follow-Up

• Repeat stool examination 2-3 weeks after completing the two-dose regimen if symptoms persist or in cases of heavy infection. 1

• If albendazole treatment extends beyond 14 days (not typical for hookworm but relevant for other helminthic infections), monitor for hepatotoxicity and leukopenia. 1

• Treatment failure is rare with the two-dose albendazole regimen; persistent symptoms usually indicate reinfection rather than drug resistance. 1

Prevention of Reinfection

• Hand hygiene and wearing shoes in endemic areas are essential preventive measures. 1

• Consider screening and treating household contacts in endemic settings to reduce transmission. 1

• For travelers returning from endemic areas with prolonged exposure (e.g., 6 years residence), empiric treatment may be warranted even with negative stool tests, as standard microscopy has limited sensitivity. 1

Clinical Pearls and Pitfalls

• Hookworm infection can present with transient itching at the site of larval skin penetration, maculopapular rash, gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal pain), and iron-deficiency anemia in heavy infections. 1

• Multiple stool samples may be needed to increase diagnostic yield due to intermittent egg shedding; a single negative stool examination does not exclude infection. 1

• Albendazole demonstrates superior efficacy compared to mebendazole or pyrantel for hookworm, with egg reduction rates exceeding 99% even with single-dose therapy. 4, 5

• The two-week repeat dosing is critical to eradicate newly hatched larvae that were not susceptible to the initial dose. 1