CP-197 Ivermectin enema elaboration for the treatment of strongyloides hyperinfection

Background Strongiloides stercolaris can produce a life threatening illness in inmunosuppressed hosts. Treatment options are limited to oral formulations and there are few data on alternative therapies.PurposeTo describe the preparation of ivermectin enema and evaluate its effectiveness in the treatment of Strongyloides hyperinfection.Material and methodsBibliographic search in Medline (keywords: ivermectin, rectal, Strongyloides) to determine the main characteristics of ivermectin enema: concentration, composition, elaboration method, packaging material, stability and storage conditions. Review of the electronic medical records and follow-up of the patient during hospitalisation.ResultsA 57-year-old man of Brazilian origin, presnted to the emergency department with nauseas, vomiting and dizziness. Imaging tests show lesions in his brain, and consequently he underwent neurosurgery. After a month the patient has haemodynamic instability and was transferred to intensive care where he was diagnosed with Strongyloides hyperinfection by wet prep of bronchial suction on 18 August 2014. Treatment was initiated with ivermectin 200 µg/kg/24 h by nasogastric tube. On 19 August, Strongyloides was isolated in faecal cultures and ivermectin enema 200 µg/kg/24 h was added to the treatment on 22 August. Since the beginning of the treatment, several microbiological controls have been done: on 25 August Strongyloides larvas were observed in bronchial suction and on 27 August in faecal cultures but with no movement capacity in both samples. On 3 and 5 September, bronchial suction and faecal cultures were done and the results were negative. Treatment by nasogastric tube and rectal ivermectin finished on 5 September.Elaboration of ivermectin enema was required by the pharmacy service because it does not exist as a commercial presentation appropriate for rectal administration. A standardised protocol was made.Elaboration process: crush ivermectin 12 mg in a mortar until it is a fine powder. Wet the powder with a small quantity of carboxymethylcellulose 1.5% until a homogeneous mixture is achieved. Add small porportions of carboxymethylcellulose up to 30 ml. Concerning stability, the enema has to be used immediately.ConclusionA protocol for the elaboration of Ivermectin enema was stablished. Treatment with rectal ivermectin added to ivermectin oral administration is an effective therapeutic option for the treatment of Strongyloides hyperinfection.References and/or Acknowledgeme