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Handbook of Nonprescription Drugs > Chapter 18. Pinworm Infection

Pinworm Infection: Introduction

Enterobius vermicularis, commonly referred to as pinworm, seatworm, threadworm, or oxyuriasis, is an intestinal nematode
and the primary agent that causes human enterobiasis. This chapter will focus on the detection and management of pinworm
infection because it is the most common worm infestation in the United States, and it is the only helminthic infection for which a
nonprescription medication has been approved for treatment. This infection is most common in temperate regions of the world;
in the United States, pinworms are found with a high prevalence in day care settings and urban areas.1,2 Although pinworms are
a nuisance, the pinworm infection presents little risk to the infected individual or the public.
Pinworm infection may be the most common helminth infection in the United States, with the greatest infection rate in children
ages 5-14 years.3 Enterobiasis is associated with all socioeconomic levels and, in contrast to other helminthic infections, does
not affect any particular race or culture. Nearly 50% of all E. vermicularis cases occur among individuals who are
institutionalized (e.g., in child care facilities or hospitals) and among family members.3,4,6

Pathophysiology of Pinworm Infection

Humans are the only hosts of E. vermicularis. Unlike most other worm infections, pinworms do not live in the soil or water and
are not transmitted through animal feces. However, animal fur of household dogs and cats may be a carrier of infective eggs.4
The most common pinworm transmission route is through ingestion of infective eggs by direct anus-to-mouth transfer by fingers
or fomites. Reinfection may occur readily. because eggs often are found under fingernails of infected children who have
scratched the anal area. Finger sucking may be considered a source of infection, particularly in children with recurring
symptoms.4 Nail biting and nose picking have not been associated with the initial infection; however, they certainly can
contribute to reinfection.5 Embryonated eggs also can be transferred from the perianal region to clothes, bedding, or bathroom
fixtures; because of their small size, pinworm eggs sometimes can become airborne in dust and reach the intestinal tract
through the nose during breathing.1,6 The eggs can remain viable outside the intestinal tract for 20 days (especially under humid
conditions) and can spread within a microcommunity (e.g., a household or school).7
After 1-2 months of molting, the adult pinworm emerges as small, white, thread-like worm with a pin-shaped, pointed tail (from
which the name is derived; see Color Plates, photograph 1A); its lifespan is about 2 months.3,7 Adult male and female worms
inhabit the first portion of the large intestine, or ileocecum, and seldom cause damage to the intestinal wall. The mature female,
approximately 8-13 mm in length, usually stores approximately 11,000 eggs in her body (see Color Plates, photograph 1B). After
her nocturnal migration down the colon and out the anus, she deposits her sticky eggs in the perianal region and dies shortly
afterward. Males are smaller (2.5 mm), live approximately 2 weeks, and do not migrate. If eggs are not washed off, they hatch
within a few hours, and larvae may return to the large intestine through the anus (retroinfection). Within 2-6 weeks of egg
ingestion, larvae are released and mature into gravid females, thus continuing the cycle indefinitely unless appropriate
behavioral and pharmacotherapeutic interventions are instituted.
Rarely, extraintestinal infestations, typically involving the genitourinary tract, may occur. As many as 36% of young girls with
urinary tract infections may be infected with pinworms because the pinworms have mistakenly crawled into the urogenital tract.1
Genitourinary pinworm infections are harder to treat because of the low systemic absorption of antiparasitic agents.7

Clinical Presentation of Pinworm Infection

Patients with minor pinworm infections often are asymptomatic. Nocturnal pruritus ani, a perianal or perineal itch, is the most
common symptom of enterobiasis.1 Perianal itching occurs predominantly at night and is caused by an inflammatory reaction to
the presence of adult worms and eggs on the perianal skin.2 Major infestations may produce symptoms ranging from abdominal
pain, insomnia, and restlessness, to anorexia, diarrhea, and intractable localized itching.4,5 Patients with severe symptoms of
major infestations and extraintestinal disease should be referred to a primary care provider (PCP) for further evaluation. Before
recommending treatment or referral, the pharmacist should ask appropriate assessment questions to rule out diaper dermatitis
in children, as well as constipation and hemorrhoids in older patients because these conditions also can cause inflammation in
the rectal region, leading to itching and discomfort.
In addition to physical signs and symptoms, psychological trauma (i.e., pinworm neurosis) to patients and parents also can
occur when worms are found near a childs anus. Patients and parents need to be assured that pinworms are common and
curable and that no social stigma is attached to their occurrence.5

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Scratching to relieve itching from pinworm infection may lead to secondary bacterial infection of the perianal and perineal
regions.7 Helminthic infections in the genital tract may lead to endometritis, salpingitis, tubo-ovarian abscess, pelvic
inflammatory disease, vulvovaginitis, and possibly infertility.7-9 Pinworms also may migrate into the peritoneal cavity and form
granulomas. Rarely, they may cause appendicitis in children.10

Treatment of Pinworm Infection

Treatment Goals

The goals of self-treatment are to relieve symptoms of pinworm infection and to eradicate pinworms from the patient and the
household, thereby preventing reinfection.

General Treatment Approach

The management of pinworm infection and prevention of reinfection includes drug treatment with pyrantel pamoate for the
patient and for every household member. Strict hygiene (e.g., washing linens and disinfecting toilet seats) is an integral part of
the treatment. Figure 18-1 outlines self-care of this infection and lists exclusions for self-treatment.

Nonpharmacologic Therapy

Once pinworm infection is suspected, the patient or caregiver should follow the nondrug measures in Table 18-1 to minimize
family and household infections and reinfections. Children can usually return to school after the first dose of an appropriate
antihelminthic agent and after their fingernails are cut and cleaned. Health care providers are in an ideal position to inform
patients of behaviors that may increase their risk of helminthic infections.

Self-care of pinworm infection. Key: OTC = Over-the-counter; PCP = primary care provider.
TABLE 18-1 Nondrug and Preventive Measures for Treating Pinworm Infection

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Educate the public in personal hygiene, particularly the need to wash hands before eating or preparing food and after using
the toilet. Encourage keeping fingernails short to prevent harboring of eggs and autoinoculation (hand-to-mouth reinfection);
discourage biting nails and scratching anal area.

Eggs are destroyed by sunlight and ultraviolet rays, so ensure blinds or curtains are open in the affected room to enhance
cleaning of the environment.

Wash bed linens, underwear, bedclothes, and towels of the infected individual and the entire family in hot water daily during
treatment. Pinworm eggs are killed by exposure to temperatures of 131F (55C) for a few seconds; therefore, the hot cycle
should be used while washing and drying.

Bathe daily in the morning; showers (stand-up baths) are preferred over tub baths.

Change underwear, nightclothes, and bed sheets daily for several days after treatment.

Clean and vacuum (do not sweep) house daily for several days after treatment of cases. Wet mopping before or instead of
vacuuming may limit spread of pinworm eggs into the air.

Reduce overcrowding in living accommodations.

Source: Heymann D. Control of Communicable Diseases Manual. 19th ed. Washington, DC: American Public Health
Association; 2008.

Pharmacologic Therapy

Pyrantel Pamoate

Pyrantel pamoate is the only nonprescription medication approved for treatment of pinworm infection. Pyrantel pamoate was
first used in veterinary practice as a broad-spectrum drug for pinworms, roundworms, and hookworms. It has become an
important drug for treating certain helminthic infections in humans. Pyrantel pamoate has a cure rate of 90%-100% when used
for treatment of enterobiasis.11 This variable cure rate may be a result of the medications lack of effect on eggs and larvae as
well as the eggs viability for up to 20 days, which may lead to reinfection.
Although this product is readily available in a nonprescription form, helminthic infections other than those caused by pinworms
require a medical referral and should be diagnosed and treated by a PCP.
Pyrantel pamoate is a depolarizing neuromuscular agent that paralyzes adult worms, causing them to loosen their hold on the
intestinal wall and subsequently be passed out in the stool before they can lay eggs. The drug is poorly absorbed, with 50%
excreted unchanged in the feces and about 7% excreted in the urine as unchanged drug and metabolites.11
A single oral dose of pyrantel pamoate (liquid, caplet, or chewable tablet) is based on the adult or child patients body weight (11
mg/kg of the pyrantel base). The maximum single dose is 1 gram. The recommended dosage is the same for children younger
than 2 years or weighing less than 25 pounds; however, they should not be treated without first consulting a PCP. The product
includes a schedule of recommended dosages that is based on a range of body weights. The dose can be repeated in 2 weeks
if symptoms do not resolve because reinfection can occur; however, the repeat dose should be administered only after
consultation with a PCP. Pyrantel pamoate may be taken at any time of the day without regard to meals, and it may be taken or
mixed with milk or fruit juice.11 A special diet or fasting before or after administration is not necessary. The liquid formulation
(containing 50 mg/mL of the pyrantel base) should be shaken well before the dose is measured.
Side effects usually are mild, infrequent, and transient. The most common adverse effects involve the gastrointestinal (GI) tract
and include nausea, vomiting, tenesmus, anorexia, diarrhea, and abdominal cramps. 12 These adverse effects are typically
related to expulsion of the helminths from the GI tract. However, a patient who experiences severe or persistent abdominal
symptoms or other side effects after taking the first or second dose of this medication should be referred to a PCP for further
evaluation. Less common side effects such as headache, dizziness, drowsiness, insomnia, rash, fever, and weakness may
occur. In very rare circumstances, transient increases in aspartate aminotransferase, ototoxicity, optic neuritis, and
hallucinations with confusion and paresthesia have been reported.11
Patients who do not respond to the recommended doses of pyrantel pamoate should be evaluated further, and the use of
prescription products should be considered. Mebendazole (Vermox) once was considered by experts to be the drug of choice to
treat pinworm infection,13,14 but it has since been discontinued by the manufacturer. The currently available prescription agent
for treatment of pinworm infection is albendazole. Albendazole is approved to treat other helminthic infections, but FDA
considers its use off label when used to treat pinworms. Albendazole is given as a single oral dose (400 mg for patients ages 2
years and older; 200 mg for patients younger than 2 years).

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Product Selection Guidelines

Pyrantel pamoate is a safe and effective treatment for pinworms. The brands listed in Table 18-2 are comparatively priced and
generally less expensive than prescription treatment (e.g., albendazole). Pyrantel pamoate is contraindicated in patients with
hypersensitivity to the drug. Patients with preexisting liver dysfunction or severe malnutrition should not self-medicate without
first consulting a PCP. Pyrantel pamoate is Pregnancy Category C and has not been studied in pregnant women; therefore, it
should be used during pregnancy only when the benefits clearly outweigh the risks, and only under the direction of a PCP.15 The
World Health Organization does not recommend the use of pyrantel pamoate during the second and third trimesters for high-risk
patients.6 Pyrantel pamoate also should not be used in patients younger than 2 years or those weighing less than 25 pounds,
unless under the direction of a PCP.
TABLE 18-2 Selected Nonprescription Pyrantel Pamoate Products

Trade Name Primary Ingredient

Pin-X Liquid/Chewable Tablet Pyrantel 50 mg/mL (base) and 250 mg/tablet (base)

Pyrantel Suspension Pyrantel 50 mg/mL (base)

Reeses Pinworm Caplet Pyrantel 180 mg (equals 62.5 mg base)

Reeses Pinworm Medicine Liquid Pyrantel 144 mg/mL (equals 50 mg/mL base)

Reeses Pinworm Medicine Family Pyrantel 144 mg/mL (equals 50 mg/mL base); contains two 1-fl oz bottles to treat the
Pack entire family

Complementary Therapies

Various home remedies (e.g., applying a combination of garlic paste and Vaseline to the anus, or ingesting coconut oil and
castor oil) and complementary therapies (e.g., white willow bark, green tea, or turmeric) have been used to treat pinworm
infection. These remedies should not be recommended because insufficient efficacy and safety evidence exists to support their
use for the treatment of pinworm infections. Because of the high risk of transmission of this infection, patients instead should
take nonprescription medications such as pyrantel pamoate or prescription medications that are approved by the Food and Drug
Administration (FDA) for pinworm infection.

Assessment of Pinworm Infection: A Case-Based Approach

Before recommending treatment, the provider should explain how to confirm a pinworm infection by any of the following
methods: (1) nighttime perianal or perineal itching in a child, (2) visual inspection of the perianal or perineal area for the adult
worm, or (3) a cellophane tape or an adhesive paddle test. Adult pinworms and eggs are seldom found in the feces; therefore,
looking for worms in the stool is not a reliable way to diagnose enterobiasis.16 When symptoms of pinworms (e.g., nocturnal
perianal or perineal itching) are present in children, nonprescription therapy may be initiated. Other more vague symptoms (e.g.,
sleep disturbances and GI complaints) should be evaluated medically before initiating nonprescription therapy. However,
asymptomatic disease is common in enterobiasis, and visual inspection may be necessary. To conduct a visual inspection, the
parent should inspect the anal area during the night with a flashlight while the child is sleeping or in the very early morning
before the child arises. White, thread-like, wriggling worms between 3 and 7 mm in length (about the size of a staple) may be
seen. If pinworms are present, treatment should be initiated. Finally, if pinworms are suspected but symptoms are vague and/or
visual inspection is negative, a PCP may instruct the patient to obtain a cellophane tape sample. The parent should apply the
sticky side of the tape to the perianal area (usually with a tongue depressor) and affix it sticky side down on a glass slide.
Commercially available kits, such as the Falcon SWUBE paddles, use a sticky paddle instead of tape to affix to a slide (see
Color Plates, photograph 1C). These pinworm paddles usually are supplied by laboratories to conduct the test. Samples should
be taken over 3 consecutive days upon the childs awakening, which may increase the likelihood of detection to around 90%.5
The samples should then be taken to a PCP for microscopic examination. If the test is positive, treatment of the pinworm
infection should be initiated.
Cases 18-1 and 18-2 illustrate the assessment of patients with pinworm infections.

Patient Counseling for Pinworm Infection

Once the decision to treat the pinworm infection with pyrantel pamoate is made, the package insert material should be reviewed
with the patient or caregiver. The insert explains the pinworm life cycle, symptoms of pinworm infection, and methods of
transmitting the infection. Doses should be calculated for the patient and all family members, and the need to treat the whole

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family should be emphasized. The patient or caregiver should be advised to implement strict hygienic measures to prevent
reinfection or transmission of the infection to other family members (Table 18-1). In addition, it should be explained that the side
effects of pyrantel pamoate usually are mild and infrequent, but that medical referral may be necessary if more severe effects
occur. Patients who experience severe or persistent symptoms after taking this medication should be referred for medical
evaluation. Finally, patients should be advised that pinworm infection symptoms (e.g., nocturnal perianal itching) should improve
within 2 weeks of treatment and that if symptoms persist or worsen to include systemic complaints (e.g., abdominal discomfort,
insomnia, and/or nervousness), medical referral may be necessary. The box Patient Education for Pinworm Infection lists
specific information to provide patients.

Evaluation of Patient Outcomes for Pinworm Infection

The patient or caregiver should be instructed to contact a PCP if anal itching persists beyond 2 weeks, if the itching recurs, or if
new symptoms develop. Because of pyrantel pamoates variable cure rate, a second dose may be required. It should be given 2
weeks after the first dose and only under the care of a PCP. In addition, the patient or caregiver should be asked about the
implementation of hygienic measures. If these measures are not being followed, their importance for preventing reinfection
should be stressed again.

Key Points for Pinworm Infection

Pinworms are common in the United States and rarely cause significant morbidity.
Health care providers should be familiar with common helminthic infections, their symptoms, and their treatment.
A medical referral may be necessary when helminths other than pinworms are suspected.
Although pyrantel pamoate is used in treating other helminthic infections, only pinworm infection should be evaluated for
self-treatment with this nonprescription agent.
Health care providers can aid patients and caregivers in the self-diagnosis, counseling, and self-treatment with
nonprescription pinworm medication.

Case 18-1

Relevant Evaluation Criteria Scenario/Model Outcome

Information Gathering

1. Gather essential information

about the patients symptoms,
including:

a. description of symptom(s)
(i.e., nature, onset, duration,
severity, associated symptoms)
A man presents to the pharmacy requesting assistance in selecting an OTC product for
his family. He reports that his daughter was diagnosed with pinworms by the pediatrician,
who recommended an OTC medication to treat the daughter as well as mom and dad. The
father says his daughter has been complaining about perianal itching that is most intense
at night. He and his wife have no current symptoms. He needs a liquid formulation
because his daughter cannot swallow tablets or capsules.

b. description of any factors that No precipitating factors

seem to precipitate, exacerbate,
and/or relieve the patients
symptom(s)

c. description of the patients The parents applied hydrocortisone cream to the childs perianal region for itching, with no
efforts to relieve the symptoms relief.

d. patients identity Daughter: Bella Turner; mother: Karen Turner; Father: Ray Turner

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Relevant Evaluation Criteria
Information Gathering
e. age, sex, height, and weight
f. patients occupation
g. patients dietary habits
h. patients sleep habits
i. concurrent medical conditions,
prescription and nonprescription
medications, and dietary
supplements
j. allergies
k. history of other adverse
reactions to medications
l. other (describe) _______
Assessment and Triage
2. Differentiate patients
signs/symptoms and correctly
identify the patients primary
problem(s).
3. Identify exclusions for
self-treatment (Figure 18-1).
4. Formulate a comprehensive
list of therapeutic alternatives for
the primary problem to
determine if triage to a medical
provider is required, and share
this information with the patients
or caregiver.
Plan
5. Select an optimal therapeutic
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Scenario/Model Outcome
Daughter: 5 years old, female, 3 ft 6 in., 39 lb; mother: 32 years old, female, 5 ft. 6 in., 143
lb; father: 36 years old, male, 5 ft 11 in., 190 lb
The father is an attorney, and his wife is a real estate agent.
Normal diet
Daughter: frequent awakenings at night caused by perianal itching; parents: normal sleep
habits
Daughter: daily childrens chewable multivitamin; mother: oral contraceptive pills, daily
multivitamin; father: fish oil capsules daily
Daughter: NKDA, mother: NKDA, father: penicillin allergy
None
The father does cardio and weight training at the gym 3 days a week.
Bella is experiencing perianal itching because of a pinworm infection, which results in
restless sleep at nights.
Patients should be excluded for self-treatment if they (1) are allergic to the OTC product,
(2) are younger than 2 years (unless treatment is approved by PCP), (3) weigh less than
25 lb (unless treatment is approved by PCP), or (4) have liver disease.
The patients do not have exclusions for self-treatment.
Options include:
(1) Recommend an appropriate OTC product (e.g., pyrantel pamoate) at appropriate
doses for each member of the family, along with nondrug therapies.
(2) Recommend that mother and father see their PCP for a prescription medication.
(3) Counsel only on environmental control measures.
(4) Take no action.
OTC treatment with pyrantel pamoate is appropriate for all three patients. The child is not
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Relevant Evaluation Criteria
Information Gathering
alternative to address the
patients problem, taking into
account patient preferences.
6. Describe the recommended
therapeutic approach to the
patients or caregiver.
7. Explain to the patients or
caregiver the rationale for
selecting the recommended
therapeutic approach from the
considered therapeutic
alternatives.
Patient Education
8. When recommending
self-care with nonprescription
medications and/or nondrug
therapy, convey accurate
information to the patients or
caregiver:
a. appropriate dose and
frequency of administration
b. maximum number of days the
therapy should be employed
c. product administration
procedures
d. expected time to onset of
relief
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Scenario/Model Outcome
comfortable swallowing tablets or caplets, but she can take chewable tablets or liquid
formulations; therefore, pyrantel pamoate is a good choice.
Both albendazole and pyrantel pamoate are effective in the treatment of pinworms.
However, pyrantel pamoate is available without a prescription, and albendazole requires a
prescription. Because one of your family members was recently diagnosed with pinworm
infection and the medical provider instructed that other family members be treated,
pyrantel pamoate is a reasonable option.
Pinworms are not life threatening and may resolve on their own. However, if the infection
is untreated, the infected person (in this case, your daughter) may reinfect herself or infect
other family members. She also may experience some complications of infection if she is
not treated. Therefore, treatment is recommended. Pyrantel pamoate is a reasonable
option because it is available without a prescription; therefore, the other family members
do not need to visit a primary care provider, which could have increased the cost of
treatment and delay its initiation. Pyrantel pamoate also is available as a chewable tablet
or an oral suspension, which offers flexible dosing that is based on weight for multiple
family members. Other formulations (e.g., tablets and caplets) are available, if preferred.
Bella (daughter) weighs 17.7 kg (39 lb); the dose of pyrantel is 11 mg/kg, so she should
receive about 195 mg. She can take 4 mL of the liquid formulation (144 mg/mL equivalent
to 50 mg/mL pyrantel base).
Karen (mom) weighs 65.0 kg, so she should receive at least 715 mg of pyrantel pamoate
(which would be approximately 3 chewable tablets or 15 mL of the liquid formulation).
Ray (dad) weighs 86.4 kg, so he should receive 950 mg of pyrantel pamoate (4 chewable
tablets or about 25 mL of the liquid formulation).
A single dose usually is required. If symptoms persist after 2 weeks, contact your primary
care provider for evaluation and, if needed, recommendation for a second dose.
Pyrantel pamoate may be taken at any time of day without regard to meals. It may be
mixed with milk or fruit juice. If using the oral suspension, shake well before
administering.
[Note: Prior to administering medication, the practitioner should verify that other family
members who need to be treated do not meet criteria for exclusion for self-treatment.
Doses will need to be calculated for the other family members.]
Relief of symptoms may take several days. The repeat dose should not be administered
until 2 weeks have elapsed and should be administered only if recommended by your
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Relevant Evaluation Criteria
Information Gathering
e. degree of relief that can be
reasonably expected
f. most common side effects
g. side effects that warrant
medical intervention should they
occur
h. patient options in the event
that condition worsens or
persists
i. product storage requirements
j. specific nondrug measures
Solicit follow-up questions from
the patient or caregiver.
Answer the patients or
caregivers questions.
Evaluation of Patient
Outcomes
9. Assess patient outcome
Key: NA = NKDA = No known drug allergies; OTC = over-the-counter; PCP = primary care provider.
Case 18-2
Relevant Evaluation Criteria
Information Gathering
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Scenario/Model Outcome
primary care provider.
Perianal itching should decrease after several days, with complete pinworm eradication
after at least 2 weeks.
Adverse effects are usually mild and may consist of nausea, vomiting, loss of appetite,
diarrhea, or abdominal cramps.
Severe or persistent abdominal symptoms require medical attention.
Contact the appropriate health care provider if any family members condition worsens, or
if any family member experiences any severe adverse effects, such as severe or
persistent abdominal symptoms, after taking the medication.
[Note: The practitioner should reinforce to the parents that pinworms are very common
and rarely cause serious problems, but that the condition will continue and potentially
spread to others if not treated.]
Store at room temperature away from direct light with container sealed tightly.
See Table 18-1.
Should my daughter receive a prescription medication instead because she has an active
infection?
Both the prescription and nonprescription medications are equally effective in treating
pinworms. You can use either the prescription medication or the nonprescription pyrantel
pamoate, depending on your preferences (such as cost).
You can call the parents in 1-2 weeks to assess the childs response to the medication. If
symptoms have resolved, reinforce the importance of hygienic measures. If symptoms
persist, another single dose of pyrantel pamoate can be administered but only after
reevaluation by the childs pediatrician.
Scenario/Model Outcome
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Relevant Evaluation Criteria
Information Gathering
1. Gather essential information about
the patients symptoms, including:
a. description of symptom(s) (i.e.,
nature, onset, duration, severity,
associated symptoms)
b. description of any factors that seem
to precipitate, exacerbate, and/or
relieve the patients symptom(s)
c. description of the patients efforts to
relieve the symptoms
d. patients identity
e. age, sex, height, and weight
f. patients occupation
g. patients dietary habits
h. patients sleep habits
i. concurrent medical conditions,
prescription and nonprescription
medications, and dietary supplements
j. allergies
k. history of other adverse reactions to
medications
Assessment and Triage
2. Differentiate patients
signs/symptoms and correctly identify
the patients primary problem(s).
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Scenario/Model Outcome
A woman presents to the pharmacy requesting assistance choosing a product to
help tie up her stomach and a product to help her with intense itching. She says
shes had loose stool and generalized abdominal pain for about 2 weeks. She
mentions that her stool has been watery most of the time and that shes noticed
little white squiggly things on the tissue after wiping. The itching, which began
approximately 10 days before the diarrhea started, is mostly in her perineal and
vaginal area and is worse at night.
No precipitating factors
She tried bismuth subsalicylate for 3 days without much relief. She took 3 doses of
loperamide, which helped the diarrhea temporarily but did not help the itching.
Shes tried applying hemorrhoidal ointment and hydrocortisone ointment to the
region to help with the itching.
Letty Whitaker
46 years old, female, 5 ft 2 in., 140 lb
Dance instructor
Normal diet, high in fruits and vegetables
Frequent awakenings at night caused by perineal itching
Daily multivitamin; occasional ibuprofen or acetaminophen for pain
NKDA
None
Patients symptoms, such as perianal itching at night, are consistent with pinworms,
but prolonged diarrhea and abdominal pain are unusual symptoms and should be
evaluated medically. The appearance of white squiggly things on the tissue may
indicate the presence of pinworms, but a tape test or a slide test must be done to
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Relevant Evaluation Criteria
Information Gathering
3. Identify exclusions for self-treatment
(Figure 18-1).
4. Formulate a comprehensive list of
therapeutic alternatives for the primary
problem to determine if triage to a
medical provider is required, and share
this information with the patient or
caregiver.
Plan
5. Select an optimal therapeutic
alternative to address the patients
problem, taking into account patient
preferences.
6. Describe the recommended
therapeutic approach to the patient or
caregiver.
7. Explain to the patient or caregiver the
rationale for selecting the
recommended therapeutic approach
from the considered therapeutic
alternatives.
Patient Education
8. When recommending self-care with
nonprescription medications and/or
nondrug therapy, convey accurate
information to the patient or caregiver.
Solicit follow-up questions from the
patient or caregiver.
Answer the patients or caregivers
questions.
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Scenario/Model Outcome
confirm infection.
Consider the patient to be excluded from self-treatment if she (1) is allergic to the
OTC product, (2) is younger than 2 years (unless treatment approved by PCP), (3)
weighs less than 25 lb (unless treatment approved by PCP), (4) has liver disease,
(5) is pregnant, (6) is breast-feeding, or (7) has vague symptoms and negative
visual inspection.
Options include:
(1) Recommend an appropriate OTC product at appropriate doses for the patient,
along with nondrug therapies.
(2) Refer the patient to a PCP for further evaluation, diagnosis, and recommended
treatment.
(3) Counsel on only environmental control measures.
(4) Take no action.
Medical evaluation by a PCP is warranted for the perineal, gastrointestinal, and
vaginal symptoms and subsequent treatment.
You should see your primary care provider for further evaluation of your
symptoms, appropriate diagnosis, and recommended treatment.
Because you have no documented pinworm infection, either by visual inspection or
by tape slide, and because you have other symptoms that may be complications of
a pinworm infection, self-treatment is not appropriate. Your symptoms may be
consistent with pinworm infection, but other possibilities need to be ruled out.
Self-treatment is not appropriate, but you should institute environmental control
measures shown in Table 18-1 and seek medical care.
(1) What are some of the complications associated with pinworms?
(2) How are pinworms normally treated?
(1) If untreated, pinworms may possibly lead to secondary bacterial infections in
the perianal and perineal regions. Pinworms also can lead to pelvic inflammatory
disease, endometritis, and urinary tract infections. In addition, other possible
symptoms associated with pinworm infection include insomnia, restlessness, and
anorexia.
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Relevant Evaluation Criteria Scenario/Model Outcome

Information Gathering

(2) Patients may be treated with a single dose of various nonprescription (pyrantel
pamoate) or prescription (albendazole) medications. Along with medications,
patients also must follow specific nondrug measures to prevent reinfection.

Evaluation of Patient Outcome

9. Assess patient outcome Ask the patient to call you in 1 week, or initiate a follow-up call to the patient to
assess whether she was evaluated by a physician and whether her symptoms are
improving.

Key: OTC = Over-the-counter; PCP = primary care provider.

Patient Education for Pinworm Infection

The objectives of self-treatment are to (1) eradicate pinworms in the infected patient, (2) prevent reinfection, and (3) prevent
transmission of the infection to others. For most patients, carefully following product instructions and the self-care measures
listed here will help ensure optimal therapeutic outcomes.
Nondrug Measures

See Table 18-1 for nondrug/preventive measures.

Nonprescription Medications

Read package insert for pyrantel pamoate information carefully; this information will help prevent reinfection or
transmission of the infection.
Consult a primary care provider before giving the medication to a person with liver disease or severe malnutrition, a child
who is younger than 2 years and/or weighs less than 25 pounds, or a woman who is pregnant or breast-feeding.
Treat all household members to ensure elimination of the infection. Medical referral may be necessary if household
members meet criteria for exclusion for self-treatment (e.g., malnutrition, pregnancy, liver disease, anemia, or age
younger than 2 years).
Take only one dose as shown on the dosing schedule included with the product. For adults and children older than 2
years, dosing is the same: 11 mg/kg taken orally. The maximum dose is 1 gram.
Shake the liquid formulation well, and use a measuring spoon to ensure an accurate dose.
If desired, pyrantel pamoate may be taken with food, milk, or fruit juices on an empty stomach any time during the day.
The liquid formulation may be mixed with milk or fruit juice.
Note that fasting, laxatives, and special diets are not necessary to aid treatment.

When to Seek Medical Attention

Seek medical attention if you experience any of the following:

Abdominal cramps, nausea, vomiting, anorexia, rash, diarrhea, headache, drowsiness, or dizziness occurs and
persists after taking the medication.
Symptoms of the pinworm infection persist beyond 2 weeks after the initial dose of pyrantel pamoate. A second
dose of pyrantel pamoate can be given if symptoms are present beyond 2 weeks, but only if directed to do so by
a primary care provider.
Rare symptoms such as vaginal itching or bleeding, pain upon urination, urinary tract infection, and hives are
present.

References

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Bethesda, MD: American Society of Health-System Pharmacists; 2010. Accessed November 2, 2010.
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