Anthelmintics

Class Summary

Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.

Albendazole (Albenza)

View full drug information

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. For pregnant women, pyrantel pamoate is the DOC.

Mebendazole (Vermox)

View full drug information

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. Available as a 100-mg chewable tablet that can be swallowed whole, chewed, or crushed and mixed with food.

Pyrantel pamoate (Pin Rid, Pin X)

View full drug information

Neuromuscular blocking agent used to slowly paralyze worm to be eliminated from GI tract. DOC during pregnancy.

Nitazoxanide (Alinia)

View full drug information

Inhibits growth of Cryptosporidium parvum sporozoites and oocysts and Giardia lamblia trophozoites. Elicits antiprotozoal activity by interfering with pyruvate-ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer reaction, which is essential to anaerobic energy metabolism. Available as a 20-mg/mL oral susp. May have activity in trichuriasis.

Ivermectin (Stromectol)

View full drug information

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. Off-label use for T trichiura in combination with albendazole or mebendazole.

Follow-up

Knopp S, Steinmann P, Keiser J, Utzinger J. Nematode infections: soil-transmitted helminths and trichinella. Infect Dis Clin North Am. 2012 Jun. 26(2):341-58. [QxMD MEDLINE Link].
Starr MC, Montgomery SP. Soil-transmitted helminthiasis in the United States: a systematic review--1940-2010. Am J Trop Med Hyg. 2011 Oct. 85(4):680-4. [QxMD MEDLINE Link].
Kappus KK, Juranek DD, Roberts JM. Results of testing for intestinal parasites by state diagnostic laboratories, United States, 1987. MMWR CDC Surveill Summ. 1991 Dec. 40(4):25-45. [QxMD MEDLINE Link].
Pullan RL, Smith JL, Jasrasaria R, Brooker SJ. Global numbers of infection and disease burden of soil transmitted helminth infections in 2010. Parasit Vectors. 2014 Jan 21. 7:37. [QxMD MEDLINE Link]. [Full Text].
Bethony J, Brooker S, Albonico M, Geiger SM, Loukas A, Diemert D. Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm. Lancet. 2006 May 6. 367(9521):1521-32. [QxMD MEDLINE Link].
Glinz D, Silue KD, Knopp S, et al. Comparing diagnostic accuracy of Kato-Katz, Koga agar plate, ether-concentration, and FLOTAC for Schistosoma mansoni and soil-transmitted helminths. PLoS Negl Trop Dis. 2010 Jul 20. 4(7):e754. [QxMD MEDLINE Link]. [Full Text].
Bundy DA, Cooper ES. Trichuris and trichuriasis in humans. Adv Parasitol. 1989. 28:107-73. [QxMD MEDLINE Link].
Lauwers G, Mino-Kenudson M, Kradin RL. Infections of the Gastrointestinal Tract. Kradin RL. Diagnostic Pathology of Infectious Disease. Philadlelphia, PA: Elsevier; 2010. 215-254.
Moser W, Schindler C, Keiser J. Efficacy of recommended drugs against soil transmitted helminths: systematic review and network meta-analysis. BMJ. 2017 Sep 25. 358:j4307. [QxMD MEDLINE Link].
Knopp S, Mohammed KA, Speich B, Hattendorf J, Khamis IS, Khamis AN. Albendazole and mebendazole administered alone or in combination with ivermectin against Trichuris trichiura: a randomized controlled trial. Clin Infect Dis. 2010 Dec 15. 51(12):1420-8. [QxMD MEDLINE Link].
Linehan M, Hanson C, Weaver A, et al. Integrated Implementation of Programs Targeting Neglected Tropical Diseases through Preventive Chemotherapy: Proving the Feasibility at National Scale. Am J Trop Med Hyg. 2011 Jan. 84(1):5-14. [QxMD MEDLINE Link]. [Full Text].
Nascimento-Carvalho CM, de Fatima Gesteira M, Azul-Neto LS, Andrade MQ. Prolonged treatment with albendazole for massive trichuriasis infection. Pediatr Infect Dis J. 2004 Nov. 23(11):1070. [QxMD MEDLINE Link].
Diaz E, Mondragon J, Ramirez E, Bernal R. Epidemiology and control of intestinal parasites with nitazoxanide in children in Mexico. Am J Trop Med Hyg. 2003 Apr. 68(4):384-5. [QxMD MEDLINE Link]. [Full Text].
Gilles HM, Hoffman PS. Treatment of intestinal parasitic infections: a review of nitazoxanide. Trends Parasitol. 2002 Mar. 18(3):95-7. [QxMD MEDLINE Link].
Pearson RD. Nitazoxanide As Treatment of Intestinal Parasites in Children. Curr Infect Dis Rep. 2004 Feb. 6(1):25-26. [QxMD MEDLINE Link].
AAP. Trichuriasis (Whipworm Infection). Red Book: 2009 Report of the Committee on Infectious Diseases. 28th. Elk Grove Village, IL: American Academy of Pediatrics; 2009. 675-6.
Arruda LK, Santos AB. Immunologic responses to common antigens in helminthic infections and allergic disease. Curr Opin Allergy Clin Immunol. 2005 Oct. 5(5):399-402. [QxMD MEDLINE Link].
Trichuriasis. Spector JM, Gibson TE. Atlas of Pediatrics in the Tropics and Resource-Limited Settings. Elk Grove Village, IL: American Academy of Pediatrics; 2009. 265-267.
Conlan JV, Khamlome B, Vongxay K, et al. Soil-Transmitted Helminthiasis in Laos: A Community-Wide Cross-Sectional Study of Humans and Dogs in a Mass Drug Administration Environment. Am J Trop Med Hyg. 2012 Apr. 86(4):624-634. [QxMD MEDLINE Link].
Cooper PJ. Interactions between helminth parasites and allergy. Curr Opin Allergy Clin Immunol. 2009 Feb. 9(1):29-37. [QxMD MEDLINE Link].
da Costa e Silva EJ, de Albuquerque SC. Trichuris trichiura. Pediatr Radiol. 2007 Feb. 37(2):239. [QxMD MEDLINE Link].
Elliott DE, Summers RW, Weinstock JV. Helminths and the modulation of mucosal inflammation. Curr Opin Gastroenterol. 2005 Jan. 21(1):51-8. [QxMD MEDLINE Link].
Ezeamama AE, Friedman JF, Acosta LP, et al. Helminth infection and cognitive impairment among Filipino children. Am J Trop Med Hyg. 2005 May. 72(5):540-8. [QxMD MEDLINE Link]. [Full Text].
Eziefula AC, Brown M. Intestinal nematodes: disease burden, deworming and the potential importance of co-infection. Curr Opin Infect Dis. 2008 Oct. 21(5):516-22. [QxMD MEDLINE Link].
Falcone FH, Pritchard DI. Parasite role reversal: worms on trial. Trends Parasitol. 2005 Apr. 21(4):157-60. [QxMD MEDLINE Link].
Flisser A, Valdespino JL, Garcia-Garcia L, et al. Using national health weeks to deliver deworming to children: lessons from Mexico. J Epidemiol Community Health. 2008 Apr. 62(4):314-7. [QxMD MEDLINE Link].
Fox LM, Furness BW, Haser JK, et al. Tolerance and efficacy of combined diethylcarbamazine and albendazole for treatment of Wuchereria bancrofti and intestinal helminth infections in Haitian children. Am J Trop Med Hyg. 2005 Jul. 73(1):115-21. [QxMD MEDLINE Link]. [Full Text].
Geary TG. Are new anthelmintics needed to eliminate human helminthiases?. Curr Opin Infect Dis. 2012 Dec. 25(6):709-17. [QxMD MEDLINE Link].
Goodman D, Haji HJ, Bickle QD, et al. A comparison of methods for detecting the eggs of Ascaris, Trichuris, and hookworm in infant stool, and the epidemiology of infection in Zanzibari infants. Am J Trop Med Hyg. 2007 Apr. 76(4):725-31. [QxMD MEDLINE Link].
Grencis RK, Cooper ES. Enterobius, trichuris, capillaria, and hookworm including ancylostoma caninum. Gastroenterol Clin North Am. 1996 Sep. 25(3):579-97. [QxMD MEDLINE Link].
Gyorkos TW, Gilbert NL, Larocque R, Casapía M, Montresor A. Re-visiting Trichuris trichiura intensity thresholds based on anemia during pregnancy. PLoS Negl Trop Dis. 2012. 6(9):e1783. [QxMD MEDLINE Link]. [Full Text].
Gyorkos TW, Maheu-Giroux M, Casapía M, Joseph SA, Creed-Kanashiro H. Stunting and helminth infection in early preschool-age children in a resource-poor community in the Amazon lowlands of Peru. Trans R Soc Trop Med Hyg. 2011 Apr. 105(4):204-8. [QxMD MEDLINE Link].
Hall A, Hewitt G, Tuffrey V, de Silva N. A review and meta-analysis of the impact of intestinal worms on child growth and nutrition. Matern Child Nutr. 2008 Apr. 4 Suppl 1:118-236. [QxMD MEDLINE Link].
Hamer D, Despommier D. Intestinal nematodes. Gorbach SL, Bartlett JG, Blacklow NR, eds. Infectious Diseases. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1998. 2003-5.
Harhay MO, Horton J, Olliaro PL. Epidemiology and control of human gastrointestinal parasites in children. Expert Rev Anti Infect Ther. 2010 Feb. 8(2):219-34. [QxMD MEDLINE Link]. [Full Text].
Hotez PJ, Arora S, Bethony J, et al. Helminth infections of children: prospects for control. Adv Exp Med Biol. 2005. 568:135-44. [QxMD MEDLINE Link].
Hutchinson SE, Powell CA, Walker SP, et al. Nutrition, anaemia, geohelminth infection and school achievement in rural Jamaican primary school children. Eur J Clin Nutr. 1997 Nov. 51(11):729-35. [QxMD MEDLINE Link].
Keiser J, Utzinger J. Efficacy of current drugs against soil-transmitted helminth infections: systematic review and meta-analysis. JAMA. 2008 Apr 23. 299(16):1937-48. [QxMD MEDLINE Link].
Knopp S, Mohammed KA, Rollinson D, Stothard JR, Khamis IS, Utzinger J. Changing patterns of soil-transmitted helminthiases in Zanzibar in the context of national helminth control programs. Am J Trop Med Hyg. 2009 Dec. 81(6):1071-8. [QxMD MEDLINE Link].
Krishnamurthy S, Samanta D, Yadav S. Trichuris dysentery syndrome with eosinophilic leukemoid reaction mimicking inflammatory bowel disease. J Postgrad Med. 2009 Jan-Mar. 55(1):76-7. [QxMD MEDLINE Link].
Kung'u JK, Goodman D, Haji HJ, Ramsan M, Wright VJ, Bickle QD. Early helminth infections are inversely related to anemia, malnutrition, and malaria and are not associated with inflammation in 6- to 23-month-old Zanzibari children. Am J Trop Med Hyg. 2009 Dec. 81(6):1062-70. [QxMD MEDLINE Link].
Levecke B, Behnke JM, Ajjampur SS, Albonico M, Ame SM, Charlier J, et al. A comparison of the sensitivity and fecal egg counts of the McMaster egg counting and Kato-Katz thick smear methods for soil-transmitted helminths. PLoS Negl Trop Dis. 2011 Jun. 5(6):e1201. [QxMD MEDLINE Link]. [Full Text].
Linehan M, Hanson C, Weaver A, Baker M, Kabore A, Zoerhoff KL, et al. Integrated implementation of programs targeting neglected tropical diseases through preventive chemotherapy: proving the feasibility at national scale. Am J Trop Med Hyg. 2011 Jan. 84(1):5-14. [QxMD MEDLINE Link]. [Full Text].
Lorenzetti R, Campo SM, Stella F, et al. An unusual endoscopic finding: Trichuris trichiura. Case report and review of the literature. Dig Liver Dis. 2003 Nov. 35(11):811-3. [QxMD MEDLINE Link].
Markell EK. Intestinal nematode infections. Pediatr Clin North Am. 1985 Aug. 32(4):971-86. [QxMD MEDLINE Link].
Mascarini-Serra LM, Telles CA, Prado MS, et al. Reductions in the prevalence and incidence of geohelminth infections following a city-wide sanitation program in a Brazilian Urban Centre. PLoS Negl Trop Dis. 2010 Feb 2. 4(2):e588. [QxMD MEDLINE Link]. [Full Text].
McSorley HJ, Maizels RM. Helminth infections and host immune regulation. Clin Microbiol Rev. 2012 Oct. 25(4):585-608. [QxMD MEDLINE Link].
Medical Economics Company. Physicians' Desk Reference. 53rd ed. Montvale, NJ: Medical Economics Co; 1999. 1442, 3018.
Moncayo AL, Vaca M, Amorim L, Rodriguez A, Erazo S, Oviedo G. Impact of long-term treatment with ivermectin on the prevalence and intensity of soil-transmitted helminth infections. PLoS Negl Trop Dis. 2008. 2(9):e293. [QxMD MEDLINE Link].
Mukhopadhyay C, Wilson G, Chawla K, Vs B, Shivananda PG. A 6 year Geohelminth infection profile of children at high altitude in Western Nepal. BMC Public Health. 2008 Mar 27. 8:98. [QxMD MEDLINE Link].
Namwanje H, Kabatereine NB, Olsen A. Efficacy of single and double doses of albendazole and mebendazole alone and in combination in the treatment of Trichuris trichiura in school-age children in Uganda. Trans R Soc Trop Med Hyg. 2011 Oct. 105(10):586-90. [QxMD MEDLINE Link].
Quihui L, Valencia ME, Crompton DW, et al. Role of the employment status and education of mothers in the prevalence of intestinal parasitic infections in Mexican rural schoolchildren. BMC Public Health. 2006. 6:225. [QxMD MEDLINE Link]. [Full Text].
Ravasi DF, O'Riain MJ, Davids F, Illing N. Phylogenetic evidence that two distinct Trichuris genotypes infect both humans and non-human primates. PLoS One. 2012. 7(8):e44187. [QxMD MEDLINE Link]. [Full Text].
Rayan P, Verghese S, McDonnell PA. Geographical location and age affects the incidence of parasitic infestations in school children. Indian J Pathol Microbiol. 2010 Jul-Sep. 53(3):498-502. [QxMD MEDLINE Link].
Reddy M, Gill SS, Kalkar SR, et al. Oral drug therapy for multiple neglected tropical diseases: a systematic review. JAMA. 2007 Oct 24. 298(16):1911-24. [QxMD MEDLINE Link].
Reina Ortiz M, Schreiber F, Benitez S, Broncano N, Chico ME, Vaca M, et al. Effects of chronic ascariasis and trichuriasis on cytokine production and gene expression in human blood: a cross-sectional study. PLoS Negl Trop Dis. 2011 Jun. 5(6):e1157. [QxMD MEDLINE Link]. [Full Text].
Sayasone S, Vonghajack Y, Vanmany M, Rasphone O, Tesana S, Utzinger J, et al. Diversity of human intestinal helminthiasis in Lao PDR. Trans R Soc Trop Med Hyg. 2009 Mar. 103(3):247-54. [QxMD MEDLINE Link].
Singh C, Zargar SA, Masoodi I, Shoukat A, Ahmad B. Predictors of intestinal parasitosis in school children of Kashmir: a prospective study. Trop Gastroenterol. 2010 Apr-Jun. 31(2):105-7. [QxMD MEDLINE Link].
Stoltzfus RJ, Albonico M, Tielsch JM, et al. School-based deworming program yields small improvement in growth of Zanzibari school children after one year. J Nutr. 1997 Nov. 127(11):2187-93. [QxMD MEDLINE Link].
Sturrock HJ, Gething PW, Clements AC, Brooker S. Optimal survey designs for targeting chemotherapy against soil-transmitted helminths: effect of spatial heterogeneity and cost-efficiency of sampling. Am J Trop Med Hyg. 2010 Jun. 82(6):1079-87. [QxMD MEDLINE Link].
Tang N, Luo NJ. Prevalence of parasites in kindergarten children. Int J Infect Dis. 2005 May. 9(3):178-9. [QxMD MEDLINE Link].
Tarafder MR, Carabin H, Joseph L, Balolong E Jr, Olveda R, McGarvey ST. Estimating the sensitivity and specificity of Kato-Katz stool examination technique for detection of hookworms, Ascaris lumbricoides and Trichuris trichiura infections in humans in the absence of a 'gold standard'. Int J Parasitol. 2010 Mar 15. 40(4):399-404. [QxMD MEDLINE Link]. [Full Text].
Tinuade O, John O, Saheed O, et al. Parasitic etiology of childhood diarrhea. Indian J Pediatr. 2006 Dec. 73(12):1081-4. [QxMD MEDLINE Link].
Tokmak N, Koc Z, Ulusan S, Koltas IS, Bal N. Computed tomographic findings of trichuriasis. World J Gastroenterol. 2006 Jul 14. 12(26):4270-2. [QxMD MEDLINE Link].
Turner JD, Jackson JA, Faulkner H, et al. Intensity of intestinal infection with multiple worm species is related to regulatory cytokine output and immune hyporesponsiveness. J Infect Dis. 2008 Apr 15. 197(8):1204-12. [QxMD MEDLINE Link].
U.S. Food and Drug Administration (FDA). Teva Product Line Changes. Available at http://www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM277319.pdf. Accessed: December 22, 2014.
Utzinger J, Botero-Kleiven S, Castelli F, Chiodini PL, Edwards H, Köhler N, et al. Microscopic diagnosis of sodium acetate-acetic acid-formalin-fixed stool samples for helminths and intestinal protozoa: a comparison among European reference laboratories. Clin Microbiol Infect. 2009 May 18. [QxMD MEDLINE Link].
Vercruysse J, Behnke JM, Albonico M, Ame SM, Angebault C, Bethony JM, et al. Assessment of the anthelmintic efficacy of albendazole in school children in seven countries where soil-transmitted helminths are endemic. PLoS Negl Trop Dis. 2011 Mar 29. 5(3):e948. [QxMD MEDLINE Link]. [Full Text].
Vercruysse J, Levecke B, Prichard R. Human soil-transmitted helminths: implications of mass drug administration. Curr Opin Infect Dis. 2012 Dec. 25(6):703-8. [QxMD MEDLINE Link].
Walden J. Parasitic diseases. Other roundworms. Trichuris, hookworm, and Strongyloides. Prim Care. 1991 Mar. 18(1):53-74. [QxMD MEDLINE Link].
Wang LJ, Cao Y, Shi HN. Helminth infections and intestinal inflammation. World J Gastroenterol. 2008 Sep 7. 14(33):5125-32. [QxMD MEDLINE Link].
Wang X, Zhang L, Luo R, Wang G, Chen Y, Medina A, et al. Soil-transmitted helminth infections and correlated risk factors in preschool and school-aged children in rural Southwest China. PLoS One. 2012. 7(9):e45939. [QxMD MEDLINE Link]. [Full Text].
Wani SA, Ahmad F, Zargar SA, Dar PA, Dar ZA, Jan TR. Intestinal helminths in a population of children from the Kashmir valley, India. J Helminthol. 2008 Dec. 82(4):313-7. [QxMD MEDLINE Link].
Wani SA, Ahmad F, Zargar SA, Dar ZA, Dar PA, Tak H, et al. Soil-transmitted helminths in relation to hemoglobin status among school children of the Kashmir Valley. J Parasitol. 2008 Jun. 94(3):591-3. [QxMD MEDLINE Link].
Wen LY, Yan XL, Sun FH, Fang YY, Yang MJ, Lou LJ. A randomized, double-blind, multicenter clinical trial on the efficacy of ivermectin against intestinal nematode infections in China. Acta Trop. 2008 Jun. 106(3):190-4. [QxMD MEDLINE Link].
Xu LQ, Yu SH, Jiang ZX, et al. Soil-transmitted helminthiases: nationwide survey in China. Bull World Health Organ. 1995. 73(4):507-13. [QxMD MEDLINE Link].
Youn H. Review of zoonotic parasites in medical and veterinary fields in the Republic of Korea. Korean J Parasitol. 2009 Oct. 47 Suppl:S133-41. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Adult T trichiura worm removed during a colonoscopy. Courtesy of the CDC (http://phil.cdc.gov/phil/home.asp).
Life cycle of whipworm. The unembryonated eggs are passed with the stool (1). In the soil, the eggs develop into a 2-cell stage (2), an advanced cleavage stage (3), and then they embryonate (4). Eggs become infective in 15 to 30 days. After ingestion in soil-contaminated hands or food, the eggs hatch in the small intestine, and release larvae (5) that mature and establish themselves as adults in the colon (6). The adult worms (approximately 4 cm in length) live in the cecum and ascending colon. The adult worms are fixed in that location, with the anterior portions threaded into the mucosa. The females begin to oviposit 60 to 70 days after infection. Female worms in the cecum shed between 3,000 and 20,000 eggs per day. The life span of the adults is about 1 year. Courtesy of the CDC (http://phil.cdc.gov/phil/home.asp).
Distribution of soil transmitted helminths (STH) Trichuris trichiura infection prevalence in 2010 based on geostatistical models for sub-Saharan Africa and available empirical information for all other regions. Courtesy of Parasites & Vectors (Pullan RL, Smith JL, Jasrasaria R, Brooker SJ. Global numbers of infection and disease burden of soil transmitted helminth infections in 2010. Parasit Vectors. 2014;7:37).
Rectal prolapse in a female child due to a parasitic Trichuris trichiura infestation. Courtesy of the CDC (http://phil.cdc.gov/phil/home.asp).
Egg from the "human whipworm". Courtesy of the CDC (http://phil.cdc.gov/phil/home.asp).

of 5

Author

Shipra Gupta, MD Assistant Professor of Pediatrics, West Virginia University School of Medicine

Shipra Gupta, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jocelyn Y Ang, MD, FAAP, FIDSA, FPIDS Clinical Professor of Pediatrics, Wayne State University School of Medicine; Professor of Pediatrics, Central Michigan University College of Medicine; Consulting Staff, Division of Infectious Diseases, Children's Hospital of Michigan

Jocelyn Y Ang, MD, FAAP, FIDSA, FPIDS is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

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

Ashir Kumar, MD, MBBS FAAP, Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS is a member of the following medical societies: Infectious Diseases Society of America, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Acknowledgements

Steven L Lanski, MD Department of Pediatrics, Division of Pediatric Emergency Medicine, Assistant Professor, Emory University and Children's Healthcare of Atlanta at Egleston

Steven L Lanski, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Tina Slusher, MD Assistant Professor, Department of Pediatrics, Section of Pediatric Critical Care, West Virginia University

Tina Slusher, MD is a member of the following medical societies: Society of Critical Care Medicine

Disclosure: Nothing to disclose.