Step 4: Treat strongyloidiasis according to clinical syndrome and diagnostic results.

Clinical syndrome	Diagnostic confirmation	Adult management	Pediatric management
Asymptomatic ± eosinophilia (including asymptomatic individuals undergoing planned immune suppression) (Very low risk)	• Serology • Stool ova and parasites (O&P) examination for larvae	Ivermectin 200 µg/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart1	Ivermectin 200 µg/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart1
Simple intestinal strongyloidiasis2 (Low risk)	• Serology • Stool O&P examination for larvae	Ivermectin 200 µg/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart1	Ivermectin 200 µg/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart1
Mild hyperinfection syndrome3 (Moderate risk)	• Serology • Stool O&P • Sputum O&P examination for larvae	Ivermectin 200 µg/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart1 PLUS Albendazole 400 mg po BID x 7 days OR, Monotherapy: Ivermectin 200 µg/kg/day po once daily x 7 days	Ivermectin 200 µg/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart1 PLUS Albendazole 400 mg po BID x 7 days OR, Monotherapy: Ivermectin 200 µg/kg/day po once daily x 7 days
Disseminated strongyloidiasis 4,5 (High risk)	• Serology • Stool O&P examination for larvae • Sputum O&P examination for larvae • Urine, cerebrospinal fluid (CSF) or other body fluid or tissue examination for larvae.	Ivermectin 200 µg/kg/day po or sc6 once daily PLUS Albendazole 400 mg po BID until cessation of larval shedding and clinical improvement	Ivermectin 200 µg/kg/day po or sc6 once daily PLUS Albendazole 400 mg po BID until cessation of larval shedding and clinical improvement

¹ A 14-day dosing interval is preferred due to the risk of prepatent infection arising from autoinfection (15).

² Characterized by weight loss, abdominal discomfort and loose stools, with or without eosinophilia.

³ Symptoms of intestinal strongyloidiasis plus respiratory symptoms (cough, wheezing, dyspnea) with or without immunosuppression (corticosteroids, HTLV-1 infection, malignancy, non-steroidal immunomodulating agents) and absence of signs of systemic toxicity or sepsis; all persons shedding larvae of Strongyloides should be screened for intercurrent HTLV-1 infection.

⁴ Severe clinical syndrome characterized by Gram-negative or polymicrobial sepsis and/or meningitis, with evidence of end-organ failure, including acute renal failure, acute respiratory distress, impaired consciousness, coma.

⁵ Patients with disseminated strongyloidiasis should also receive empiric coverage of polymicrobial sepsis with broad-spectrum antibiotics.

⁶ Available only as a veterinary formulation; use in humans is off-label and not Health Canada approved (25,31-33)