eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Hookworm Infection: Treatment & Medication

Author: Christopher M Watson, MD, Pediatric Critical Care Fellow, Johns Hopkins Hospital; Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences
Coauthor(s): Patrick W Hickey, MD, FAAP, Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Pediatrics, Division of Pediatric Infectious Disease, Walter Reed Army Medical Center
Contributor Information and Disclosures

Updated: Oct 7, 2008

Treatment

Medical Care

  • In the United States, chemotherapeutics available for treatment of hookworm disease include the benzimidazoles (mebendazole and albendazole) and pyrantel pamoate. Benzimidazoles are an effective chemotherapeutic option with cure rates greater than 90% after a full course of treatment. However, reinfection remains a notable problem because exposure to the hookworm does not confer long-term immunity.14
  • Iron supplements improve motor and language development in infected children.15,16,17
  • Nutritional support, including folate supplementation, may also be beneficial, especially if the patient is malnourished.

Medication

In the past, treatment of pregnant or lactating women was discouraged because of concerns about potential teratogenicity. These populations are now recognized as being at high risk in endemic regions, and treatment may be warranted after careful clinical consideration of the risks and benefits. Treatment may be indicated because of the high neonatal and maternal morbidity and mortality rates.

Published reports about the use of albendazole or mebendazole in children younger than 6 years are limited. In 2007, two randomized clinical trials were conducted in Vietnam among schoolchildren, aged 6-11 years.18  The initial study compared the efficacy of single-dose mebendazole to placebo. In this study, single-dose mebendazole was found to not significantly reduce the disease burden as determined by fecal sample egg counts. In the follow-up randomized clinical trial of children aged 16 years and older, triple-dose mebendazole, triple-dose albendazole, and single-dose albendazole were compared to placebo. The findings in this study revealed greater efficacy of triple-dose albendazole in these children; the cure rate for triple-dose albendazole was 79%, compared with cure rates of 26% for triple-dose mebendazole, 45% for single-dose albendazole, and 35% for placebo.

Limited studies such as these reiterate that drug pharmacokinetics and pharmacodynamics may be altered in pediatric populations and warrant additional studies.

The US Food and Drug Administration (FDA) has approved mebendazole for the treatment of hookworm in children older than 2 years. Albendazole is used off-label for hookworm treatment and is not advised for use in children younger than 6 years. Given this information, the following section represents treatment recommendations. The potential benefits and risks must be considered before treatment is started.

Antihelmintics

Parasitic biochemical pathways differ from those in the human host. Therefore, toxicity is directed to the parasite, egg, or larvae. Mechanisms of action vary in the drug class. Antiparasitic actions may include the following:

  1. Inhibition of microtubules, which irreversibly blocks glucose uptake
  2. Inhibition of tubulin polymerization
  3. Depolarizing neuromuscular blockade
  4. Inhibition of cholinesterase
  5. Increased permeability of the cell membrane resulting in intracellular calcium loss
  6. Vacuolization of the schistosome tegument
  7. Increased permeability of the cell membrane to chloride ions due to alteration of chloride channels


Albendazole (Albenza)

Benzimidazole carbamate that inhibits tubulin polymerization, resulting in degeneration of cytoplasmic microtubules. Decreases production of adenosine triphosphate (ATP) in the worm, causing its energy depletion, immobilization, and finally death. Converted in liver to its primary metabolite, albendazole sulfoxide. Less than 1% of primary metabolite excreted in urine. Plasma level substantially rises (as much as 5-fold) when ingested after high-fat meal.

Adult

Classic hookworm disease and eosinophilic enteritis: 400 mg PO once
Cutaneous larva migrans: 400 mg PO qd for 3 d

Pediatric

<6 years: Not established
>6 years: Administer as in adults

Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity

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 results of liver function tests (LFTs) increase substantially (resume when levels decrease to pretest values); abdominal pain, nausea, vomiting, diarrhea, dizziness, vertigo, fever, increased intracranial pressure, and alopecia may occur


Mebendazole (Vermox)

Recommended for treatment of eosinophilic enteritis; inhibits microtubule polymerization by binding to cytoplasmic b-tubulin; by affecting intestinal cells of parasite, prevents its use of nutrients and essentially starves it to death; dose below selectively toxic to parasites because binds to parasite b-tubulin at concentrations lower than those needed to bind mammalian protein; because acts locally on worms in GI tract, systemic drug concentration does not dictate action.
Repeat stool examination with a concentration technique recommended after 2 wk. Retreatment indicated if results positive. No fasting or purging required. Tab may be chewed, swallowed, or crushed and mixed with food.

Adult

100 mg PO bid for 3 d or 500 mg PO once; in some studies, cure rates best with multidose regimen

Pediatric

<2 years: Not established
>2years: Administer as in adults

Carbamazepine and phenytoin may decrease effects; cimetidine may increase levels

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


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

FDA approved but considered investigational for this condition. Depolarizing neuromuscular blocking agent that inhibits cholinesterases, resulting in spastic paralysis of worm.

Adult

11 mg/kg (5 mg/lb) PO qd for 3 d, not to exceed 1 g/dose, may administer without regard to ingestion of food or time of day

Pediatric

<2 years: Not established
>2 years: Administer as in adults

In ascariasis, pyrantel and piperazine mutually antagonistic and should not be used concomitantly; in pediatric patients, theophylline serum levels may increase

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 Hookworm Infection

Overview: Hookworm Infection
Differential Diagnoses & Workup: Hookworm Infection
Treatment & Medication: Hookworm Infection
Follow-up: Hookworm Infection
Multimedia: Hookworm Infection
References
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References

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  2. World Health Organization. Parasitic Diseases. WHO. Available at http://www.who.int/vaccine_research/diseases/soa_parasitic/en/index2.html. Accessed September 6, 2008.

  3. Capello M, Hotez PJ. Chapter 276: Intestinal Nematodes. In: Long SS, ed-in-chief; Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Philadelphia, PA: Churchill Livingstone, an imprint of Elsevier Science; 2008:1298-1300.

  4. Gilles HM. Soil-transmitted Helminths (Geohelminths). In: Cook GC, Zumla AI, eds. Manson's Tropical Diseases. 2003. ed. Philadelphia, PA: WB Saunders; 1538-60.

  5. Centers for Disease Control and Prevention. Hookworm. CDC DPDx: Laboratory Identification of Parasites of Public Health Concern. Available at http://www.dpd.cdc.gov/DPDx/HTML/Hookworm.htm. Accessed September 6, 2008.

  6. Centers for Disease Control and Prevention. Hookworm Infection. CDC. Available at http://www.cdc.gov/ncidod/dpd/parasites/hookworm. Accessed September 6, 2008.

  7. Hotez PJ, Brooker S, Bethony JM, Bottazzi ME, Loukas A, Xiao S. Hookworm infection. N Engl J Med. Aug 19 2004;351(8):799-807. [Medline].

  8. Hotez PJ, Bethony J, Bottazzi ME, Brooker S, Buss P. Hookworm: "the great infection of mankind". PLoS Med. Mar 2005;2(3):e67. [Medline].

  9. Quinnell RJ, Bethony J, Pritchard DI. The immunoepidemiology of human hookworm infection. Parasite Immunol. Nov-Dec 2004;26(11-12):443-54. [Medline].

  10. Brooker S, Bethony J, Hotez PJ. Human hookworm infection in the 21st century. Adv Parasitol. 2004;58:197-288. [Medline].

  11. Bungiro R, Cappello M. Hookworm infection: new developments and prospects for control. Curr Opin Infect Dis. Oct 2004;17(5):421-6. [Medline].

  12. AAP. Hookworm infections. In: Red Book 2006: Report of the Committee on Infectious Diseases. 27th ed. American Academy of Pediatrics; 2006:374-5.

  13. Stoltzfus RJ, Albonico M, Tielsch JM, Chwaya HM, Savioli L. Linear growth retardation in Zanzibari school children. J Nutr. Jun 1997;127(6):1099-105. [Medline].

  14. Bethony J, Brooker S, Albonico M, Geiger SM, Loukas A, Diemert D, et al. Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm. Lancet. May 6 2006;367(9521):1521-32. [Medline].

  15. Stoltzfus RJ, Chway HM, Montresor A, et al. Low dose daily iron supplementation improves iron status and appetite but not anemia, whereas quarterly anthelminthic treatment improves growth, appetite and anemia in Zanzibari preschool children. J Nutr. Feb 2004;134(2):348-56. [Medline].

  16. Stoltzfus RJ, Kvalsvig JD, Chwaya HM, et al. Effects of iron supplementation and anthelmintic treatment on motor and language development of preschool children in Zanzibar: double blind, placebo controlled study. BMJ. Dec 15 2001;323(7326):1389-93. [Medline].

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  25. Larocque R, Casapia M, Gotuzzo E, et al. A double-blind randomized controlled trial of antenatal mebendazole to reduce low birthweight in a hookworm-endemic area of Peru. Trop Med Int Health. Oct 2006;11(10):1485-95. [Medline].

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Further Reading

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Keywords

hookworm infection, Ancylostomatidae, ancylostomiasis, Necator americanus, N americanus, A duodenale, Ancylostoma duodenale, ground itch, anemia, malnutrition, eosinophilic enteritis, hypoproteinemia, pruritic dermatitis, Wakana syndrome, Loeffler syndrome, pulmonary infection, pica, syncope

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Contributor Information and Disclosures

Author

Christopher M Watson, MD, Pediatric Critical Care Fellow, Johns Hopkins Hospital; Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences
Christopher M Watson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Patrick W Hickey, MD, FAAP, Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Pediatrics, Division of Pediatric Infectious Disease, Walter Reed Army Medical Center
Patrick W Hickey, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

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.

CME Editor

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 Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap 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: None None None

 
 
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