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Pediatric Ascariasis Medication

  • Author: William H Shoff, MD, DTM&H; Chief Editor: Russell W Steele, MD  more...
Updated: Jan 05, 2015

Medication Summary

Several drugs are efficacious for the treatment of ascariasis, including the asymptomatic intestinal phase; this involves the periodic deworming of children (symptomatic and asymptomatic), a reduction of the public health burden in selected communities, treatment during the pulmonary phase (rarely), and treatment of complications of the infection (some but not all).

The drugs of choice in the United States include pyrantel pamoate and the benzimidazoles, albendazole and mebendazole. The efficacy for albendazole, mebendazole, and pyrantel is 88%, 95%, and 88%, respectively. For hookworm, a common infecting STH, the efficacies for the same medications are 72%, 15%, and 31%, respectively; therefore, using albendazole is more efficacious, when a coinfection of ascaris and hookworm is suspected.

In general, antihelminthic drugs are not recommended in patients from endemic areas (areas with large worm burdens) who have acute abdominal pain, with or without partial bowel obstruction, because of the risk of precipitating complete obstruction. This complication has particularly been associated with pyrantel pamoate, which causes a spastic (depolarizing) paralysis of the worms, increasing the potential for worm bolus formation; however, this complication has also been reported in association with piperazine, mebendazole, and albendazole. In cases with acute abdominal symptoms, conservative treatment is best and the antihelminthic should be administered after symptoms subside (see Medical Care).

In pregnancy, the drug of choice is pyrantel pamoate. It is recommended in symptomatic cases only and should be administered after the symptoms subside in response to conservative therapy (see Medical Care).

Two other alternative medications with demonstrated efficacy in the treatment of ascariasis include nitazoxanide, which was approved by the US Food and Drug Administration (FDA) in December 2002 for treatment of Giardia lamblia and Cryptosporidium parvum in patients aged 1-11 years, and levamisole, which was FDA approved in June 1990 for use in treatment of colon cancer and although has demonstrated efficacy in the treatment of ascariasis since at least the early 1980s.

Albendazole has the advantages of pediatric dosing for individuals younger than 2 years, good tolerability, and efficacy in the treatment of ascariasis, hookworm infection, pinworm infection, strongyloidiasis, and trichuriasis. Nitazoxanide has similar efficacy, but dosing has not been established in patients younger than 1 year.

The World Health Organization (WHO) recommends 4 drugs in STH control programs (ie, ascariasis, hookworm infection, pinworm infection, strongyloidiasis, and trichuriasis): albendazole, levamisole, mebendazole, and pyrantel embonate.[20, 21] All four have a cure rate of more than 90% in patients with ascariasis. Albendazole has a 60-90% cure rate for hookworm infection, 20-90% for strongyloidiasis and trichuriasis, and more than 90% for pinworm infection. Mebendazole is somewhat less efficacious. Levamisole is somewhat less efficacious for hookworm infection (20-90% cure rate) but significantly less so (20-60% cure rate) for pinworm infection, strongyloidiasis, and trichuriasis. Pyrantel embonate has poor efficacy (0-20% cure rate) for strongyloidiasis and trichuriasis.

In developing countries, many patients (50-92%) with acute abdominal symptoms compatible with partial and/or subacute bowel obstruction and a high degree of suspicion for ascariasis as the etiology (5-35% of all obstructions) respond to conservative measures without requiring surgery or progressing to sepsis (see Medical Care).


Anthelmintic agents

Class Summary

Parasite biochemical pathways are different from the human host; thus, toxicity is directed to the parasite, egg, or larvae. Mechanism of action varies within the drug class.

Mebendazole (Emverm)


Causes worm death by selectively and irreversibly blocking uptake of glucose and other nutrients in susceptible adult intestine where helminths dwell. Causes slow immobilization and death of organisms. Administration over 3 d reduces risk of worm bolus formation. Available as a 100-mg chewable tablet that can be swallowed whole, chewed, or crushed and mixed with food.

Albendazole (Albenza)


Broad-spectrum anthelmintic agent effective against Ascaris species, hookworm, tapeworm, liver fluke, and pinworms. Decreases ATP production in worm, causing energy depletion, immobilization, and finally death.

Pyrantel pamoate (Antiminth, Pin-Rid, Pin-X)


Depolarizing neuromuscular blocking agent. Inhibits cholinesterases, resulting in spastic paralysis of worm. Poorly absorbed from GI tract and partially metabolized in liver.

Piperazine citrate (Vermizine)


No longer available in the United States. Causes flaccid paralysis of the helminth by blocking response of Ascaris species worm to acetylcholine; thus, expels the worm by normal intestinal peristalsis. Readily absorbed from GI tract, partially degraded in vivo, and excreted in urine. Exhibits wide therapeutic index.

The dose of piperazine citrate is expressed in terms of piperazine hexahydrate. For example, piperazine hexahydrate 250 mg = the anhydrous form of piperazine citrate 275.75 mg. The PO solution is equivalent to 500 mg/5 mL of piperazine hexahydrate. The dosage for piperazine (granules) solution, susp, and tabs are not interchangeable.

Ivermectin (Stromectol)


Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Half-life is 16 h; metabolized in liver.

Levamisole (Ergamisol)


Not available in the United States. L-isomer of tetramisole, a potent anthelmintic. Has demonstrated a broad range of pharmacologic activities, some of which include the modulation of the immune system. Restores immune function and stimulates T-cell activation and proliferation, monocyte function and neutrophil chemotaxis, adhesion, and mobility.

Nitazoxanide (Alinia)


Elicits antiprotozoal activity by interference with pyruvate:ferredoxin oxidoreductase (PFOR) enzyme–dependent electron transfer reaction, which is essential to anaerobic energy metabolism. Available as a PO suspension (20 mg/mL).

Contributor Information and Disclosures

William H Shoff, MD, DTM&H Director, PENN Travel Medicine; Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.


Catherine T Shoff, DO Staff Physician, Departments of Pulmonary, Critical Care and Sleep Medicine, Director, Tri-Services Adult Cystic Fibrosis Center, Wilford Hall Medical Center; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences

Catherine T Shoff, DO is a member of the following medical societies: American College of Chest Physicians, American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Martin Weisse, MD Program Director, Associate Professor, Department of Pediatrics, West Virginia University

Martin Weisse, MD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Michael D Nissen, MBBS FRACP, FRCPA, Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital

Michael D Nissen, MBBS is a member of the following medical societies: American Academy of Pediatrics, Royal College of Pathologists of Australasia, Royal Australasian College of Physicians, American Society for Microbiology, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.


Michael E Greenberg, MD, MPH Clinical Instructor, Department of Pediatrics, University of California at San Francisco

Michael E Greenberg, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, and American Public Health Association

Disclosure: Nothing to disclose.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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The roundworm Ascaris lumbricoides causes ascariasis. Worms can reach 10-30 cm in length. Clinical disease results from effects of pulmonary larval migration, intestinal obstruction, or migration through the biliary tree.
Table 1. Major Soil-Transmitted Helminths [1, 2]
Parasite* Disease Prevalence
A lumbricoides Common roundworm infection, ascariasis 800 million to 1.4 billion
T trichiura Whipworm infection, trichuriasis 600 million to 1 billion
Necator americanus and

Ancylostoma duodenale

Hookworm infection 580 million to 1.2 billion
Strongyloides stercoralis Threadworm infection, strongyloidiasis 30-300 million
Enterobius vermicularis Pinworm infection 4-28% of children
Toxocara canis and

Toxocara cati

Visceral larva migrans and ocular larva migrans 2-80% of children
*All major parasites are found in tropical, subtropical, and temperate climates.
Table 2. Minor Soil-Transmitted Helminths [1, 2]
Minor Parasite Disease Distribution
Ancylostoma braziliense Cutaneous larva migrans Costal regions worldwide
Uncinaria stenocephala Cutaneous larva migrans Costal regions worldwide
Ancyclostoma canium Eosinophilic enteritis Australia
Ancylostoma ceylanicum Hookworm infection Asia
Oesophagostomum bifurcum Nodular worm infection North America
Strongyloides fuelleborni Swollen belly syndrome West Africa
Ternidens diminutus False hookworm infection Southern Africa
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