eMedicine Specialties > Infectious Diseases > Parasitic Infections
Ascariasis: Treatment & Medication
Updated: Sep 12, 2008
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Treatment
Medical Care
Because of the risk of complications, patients with ascariasis who have other concomitant helminthic infections should always undergo treatment for ascariasis first. Medical therapy is usually not indicated during active pulmonary infection because dying larvae are considered a higher risk for significant pneumonitis. Pulmonary symptoms may be ameliorated with inhaled bronchodilator therapy or corticosteroids, if necessary.
- Albendazole 400 mg one dose orally is the drug of choice. Ascariasis commonly coexists with whipworm infection, which appears to be more susceptible to albendazole than to mebendazole. Albendazole is not recommended during pregnancy; pyrantel pamoate is the drug of choice in these cases.
- Alternative therapy is mebendazole (100 mg bid for 3 d or 500 mg as a single dose). Mebendazole is not recommended during pregnancy; pyrantel pamoate is the drug of choice in these cases.
- Paralyzing vermifuges (eg, pyrantel pamoate, piperazine, ivermectin) should be avoided in patients with complete or partial intestinal obstruction since the paralyzed worms may necessitate or further complicate surgery.
- Vitamin A supplementation improved growth development of children in Zaire; deworming did not improve growth development in this study.13
- Drug therapy affects only adult worms. If the patient lives in an endemic area or has recently relocated, he or she may still be carrying larvae that are not yet susceptible. Such patients should be re-evaluated in 3 months and retreated if stool ova persist. In endemic areas, reinfection rates approach 80% within 6 months.
- Nitazoxanide, a drug used primarily for protozoal infection, was shown to have 89% clinical efficacy for the treatment of ascariasis in rural Mexico and may offer a future alternative to other medications.14
Surgical Care
Conservative management of partial intestinal obstruction and biliary ascariasis is usually effective. The patient is maintained on nothing-by-mouth status, and the partial obstruction usually spontaneously resolves. Preventing oral intake decreases the risk of food compounding the obstruction while normal peristalsis redistributes or evacuates the worms. A controlled trial from Pakistan found that, in patients without peritonitis, hypertonic saline enemas relieved obstruction more quickly (1.6 d vs 3.4 d) and resulted in shorter hospital stays (4 d vs 6 d) than intravenous fluids alone. A recent study from India demonstrated that conservative therapy was successful in 19 of 22 (89%) children with intestinal obstruction. The regimen used consisted of no oral intake, intravenous fluids, antibiotics, piperazine salt per nasogastric tube, and glycerine plus liquid paraffin emulsion enemas.9
- Recommended criteria for surgical exploration include the following:
- Passage of blood per rectum
- Multiple air fluid levels on abdominal radiographs
- An ill child with abdominal distension and rebound tenderness
- Unsatisfactory response to conservative therapy
- Appendicitis and primary peritonitis
- Hepatobiliary disease
- Pancreatic pseudocyst
- Most (49-90%) worms eventually migrate from the biliary system spontaneously. Drug therapy should be delayed in patients with right upper quadrant or pancreatic pain, as no evidence has shown that drugs are active against worms located in the biliary tree. Regardless, death of the worm in the duct may provoke both inflammation and obstruction. Patients with ascariasis who have only minor symptoms can undergo observation for 3 days. If the minor symptoms persist after 3 days or the patient develops frank cholangitis or pancreatitis, removal of the worms with ERCP should be attempted, if available. Although technically challenging at times, ERCP extraction rates have exceeded 90%.11
- Intestinal or biliary surgery may be necessary for complications of ascariasis.
- Intestinal gangrene usually occurs at the terminal ileum, more often after the use of pyrantel pamoate, which tetanically paralyzes worms and thereby enhances the risk of obstruction. Recently, 2 cases of delayed distal intestinal disease have been reported, which were thought to be secondary to toxins from the worms. Therefore, patients should probably be monitored for some time after the surgical removal of worms.
- Milking of worms to the large bowel, resection of gangrenous bowel, ileostomy, and enterotomy are the most common surgical procedures used to manage bowel obstruction.
- Invasion of the gall bladder necessitates cholecystectomy, common duct exploration, and T-tube drainage until the patient is stabilized and dewormed.
- Any elective gastrointestinal surgery in patients with ascariasis should be delayed until they have been dewormed and adequately nourished. In particular, patients who live in endemic areas should be dewormed before and after elective cholecystectomy.
Medication
The goals of pharmacotherapy are to eradicate infestation, to prevent complications, and to reduce morbidity.
Anthelmintic agents
Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.
Albendazole (Albenza)
First DOC. A benzimidazole carbamate drug that inhibits tubulin polymerization, resulting in degeneration of cytoplasmic microtubules. Decreases ATP production in worms, causing energy depletion, immobilization, and, finally, death. Converted in the liver to its primary metabolite, albendazole sulfoxide. Less than 1% of the primary metabolite is excreted in the urine. Plasma level is noted to rise significantly (as much as 5-fold) when ingested after high-fat meal. Experience with patients <6 y is limited.
To avoid inflammatory response in CNS, patient must also be started on anticonvulsants and high-dose glucocorticoids.
Well tolerated and does not appear to increase risk of worm obstruction.
Adult
400 mg PO single dose
Pediatric
Administer as in adults
Carbamazepine and phenytoin may decrease effects of albendazole; cimetidine may increase albendazole levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in hepatic impairment
Mebendazole (Vermox)
Well tolerated and does not appear to increase risk of worm obstruction. Causes worm death by selectively and irreversibly blocking uptake of glucose and other nutrients in susceptible adult intestine where helminths dwell.
Adult
500 mg PO once or 100 mg PO bid for 3 d
Pediatric
Administer as in adults
Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue use if LFTs increase significantly (resume when levels decrease to pretest values); abdominal pain, nausea, vomiting, diarrhea, dizziness, vertigo, fever, increased intracranial pressure, and alopecia may occur
Pyrantel pamoate (Pin-Rid, Reese's Pinworm Medicine)
Neuromuscular blocking agent used to slowly paralyze worm to be eliminated from GI tract. May be DOC during pregnancy.
Adult
11 mg/kg PO to maximum of 1 g
Pediatric
<2 years: Do not use
>2 years: Administer as in adults
In ascariasis, pyrantel and piperazine are mutually antagonistic and should not be used concomitantly; theophylline serum levels may increase in pediatric patients following pyrantel pamoate administration
Documented hypersensitivity; hepatic disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver impairment, anemia, and malnutrition
More on Ascariasis |
| Overview: Ascariasis |
| Differential Diagnoses & Workup: Ascariasis |
 Treatment & Medication: Ascariasis |
| Follow-up: Ascariasis |
| Multimedia: Ascariasis |
| References |
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Further Reading
Keywords
ascariasis, helminthic infection, Ascaris lumbricoides, A lumbricoides, nematodes, roundworm, chronic ascariasis, acute ascariasis, biliary ascariasis, ascarids, geophagy, night soil, Ascaris lumbricoides suum, A lumbricoides suum, A suum, pig manure
