Management of strongyloidiasis in immunocompromised patients
For information on primary prophylaxis and pre-emptive treatment of Strongyloides stercoralis in immunocompromised adults, see Strongyloides stercoralis prophylaxis in immunocompromised adults without HIV infection.
Immunocompromised patients can develop hyperinfection or disseminated strongyloidiasis syndrome, which can be fatal. Patients at risk include those receiving high-dose or prolonged corticosteroids (eg prednisolone 20 mg daily or more [or equivalent, see Corticosteroid doses approximately equivalent to prednisolone 20 mg daily] for more than 2 weeks) or other potent immunosuppressive drugs (eg used for chemotherapy or following organ transplant), or who have human T-lymphotropic virus type 1 infection, haematological malignancy or advanced HIV infection.
In immunocompromised patients with uncomplicated strongyloidiasis, use:
ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, on days 1, 2, 15 and 16. ivermectinivermectinivermectin
Immunocompromised patients with hyperinfection or disseminated strongyloidiasis syndrome need longer courses of therapy, together with reduction of immunosuppression therapy if possible. There is limited evidence on optimal treatment—seek expert advice. The duration of treatment is based on clinical response. A regimen that has been used is:
ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally or enterally with fatty food, daily until symptoms resolve and stool or sputum microscopy demonstrates clearance of larvaeivermectinivermectinivermectin
FOLLOWED BY TWO FURTHER DOSES:
ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally or enterally with fatty food, daily on days 7 and 8 after completion of daily therapy.ivermectinivermectinivermectin
In patients who are not improving clinically or who are not absorbing enteral feeds, consider administering ivermectin subcutaneously1 instead of via the oral or enteral route (using the same dosage as above), continued until microscopy demonstrates clearance of larvae.
Patients who remain immunocompromised require follow-up clinical assessment and serology to check for relapse.
Following treatment of strongyloidiasis, immunocompromised patients who live in or visit a Strongyloides-endemic region (eg remote Aboriginal and Torres Strait Islander communities) should receive ongoing prophylaxis:
ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, once every 3 months while the patient remains immunocompromised and continues to live in or visit an endemic area.ivermectinivermectinivermectin
For immunocompromised children weighing less than 15 kg, seek expert advice.