Pediatric Ascariasis Medication

  • Author: William H Shoff, MD, DTM&H; Chief Editor: Russell W Steele, MD   more...
 
Updated: Sep 27, 2010
 

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 co-infection 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. Incases 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.[17, 18] 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).

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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.

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Mebendazole (Vermox)

 

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.

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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.

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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.

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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.

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Levamisole (Ergamisol)

 

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.

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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).

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Contributor Information and Disclosures
Author

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

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, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

Coauthor(s)

Catherine T Shoff, DO  Staff Physician, Departments of Pulmonary, Critical Care and Sleep Medicine, Director, Tri-Services Adult Cystic Fibrosis Ctr, 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 Academy of Sleep Medicine and American College of Chest Physicians

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.

Specialty Editor Board

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, FRACP, FRCPA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Pediatric Infectious Diseases Society, Royal Australasian College of Physicians, and Royal College of Pathologists of Australasia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

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: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

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, and Southern Medical Association

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*DiseasePrevalence
A lumbricoidesCommon roundworm infection, ascariasis800 million to 1.4 billion
T trichiuraWhipworm infection, trichuriasis600 million to 1 billion
Necator americanus and



Ancylostoma duodenale



Hookworm infection580 million to 1.2 billion
Strongyloides stercoralisThreadworm infection, strongyloidiasis30-300 million
Enterobius vermicularisPinworm infection4-28% of children
Toxocara canis and



Toxocara cati



Visceral larva migrans and ocular larva migrans2-80% of children
*All major parasites are found in tropical, subtropical, and temperate climates.
Table 2. Minor Soil-Transmitted Helminths[1, 2]
Minor ParasiteDiseaseDistribution
Ancylostoma brazilienseCutaneous larva migransCostal regions worldwide
Uncinaria stenocephalaCutaneous larva migransCostal regions worldwide
Ancyclostoma caniumEosinophilic enteritisAustralia
Ancylostoma ceylanicumHookworm infectionAsia
Oesophagostomum bifurcumNodular worm infectionNorth America
Strongyloides fuelleborniSwollen belly syndromeWest Africa
Ternidens diminutusFalse hookworm infectionSouthern Africa
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