1. Dr L. Nabarro Professor P.L.Chiodini
Current Management of Cystic Echinococcosis; a survey of specialist practice
Dr L. Nabarro
Professor P.L.Chiodini

2. What are you doing?

3. Further investigation
Patient 1
34 year old M
Abdominal pain
9x9x10cm hepatic cyst
ALT 197, ALP257, EO 2
Hydatid IgG positive
KEY CONCERN
PAIR for type 2
% used
Pre procedure BMZ therapy
Post procedure BMZ therapy
Expert consensus guidance
Watch and wait
2.5
Contraindicated (progression)
Drug therapy alone
Contraindicated (failure)
PAIR
12.5
4d to 6 months
3 weeks to 6 months
Contraindicated (recurrence)
Other percutaneous intervention (PEVAC) 10
1 week to 1 month
1 month to 6 months
With drug cover (length not specified)
Surgery
62.5
0-6 months
1month to 1 year
With drug cover (1 day pre to 1month post)
Other
Further investigation

4. Further investigation
Patient 1
34 year old M
Abdominal pain
9x9x10cm hepatic cyst
ALT 197, ALP257, EO 2
Hydatid IgG positive
KEY CONCERN
PAIR for type 2
% used
Pre procedure BMZ therapy
Post procedure BMZ therapy
Expert consensus guidance
Watch and wait
2.5
Contraindicated (progression)
Drug therapy alone
Contraindicated (failure)
PAIR
12.5
4d to 6 months
3 weeks to 6 months
Contraindicated (recurrence)
Other percutaneous intervention (PEVAC) 10
1 week to 1 month
1 month to 6 months
With drug cover (length not specified)
Surgery
62.5
0-6 months
1month to 1 year
With drug cover (1 day pre to 1month post)
Other
Further investigation

5. Further investigation
Patient 1
34 year old M
Abdominal pain
9x9x10cm hepatic cyst
ALT 197, ALP257, EO 2
Hydatid IgG positive
KEY CONCERN
PAIR for type 2
% used
Pre procedure BMZ therapy
Post procedure BMZ therapy
Expert consensus guidance
Watch and wait
2.5
Contraindicated (progression)
Drug therapy alone
Contraindicated (failure)
PAIR
12.5
4d to 6 months
3 weeks to 6 months
Contraindicated (recurrence)
Other percutaneous intervention (PEVAC) 10
1 week to 1 month
1 month to 6 months
With drug cover (length not specified)
Surgery
62.5
0-6 months
1month to 1 year
With drug cover (1 day pre to 1month post)
Other
Further investigation

6. Further investigation
Patient 1
34 year old M
Abdominal pain
9x9x10cm hepatic cyst
ALT 197, ALP257, EO 2
Hydatid IgG positive
KEY CONCERN
PAIR for type 2
% used
Pre procedure BMZ therapy
Post procedure BMZ therapy
Expert consensus guidance
Watch and wait
2.5
Contraindicated (progression)
Drug therapy alone
Contraindicated (failure)
PAIR
12.5
4d to 6 months
3 weeks to 6 months
Contraindicated (recurrence)
Other percutaneous intervention (PEVAC) 10
1 week to 1 month
1 month to 6 months
With drug cover (length not specified)
Surgery
62.5
0-6 months
1month to 1 year
With drug cover (1 day pre to 1month post)
Other
Further investigation

7. Further investigation
Patient 1
34 year old M
Abdominal pain
9x9x10cm hepatic cyst
ALT 197, ALP257, EO 2
Hydatid IgG positive
KEY CONCERN
PAIR for type 2
% used
Pre procedure BMZ therapy
Post procedure BMZ therapy
Expert consensus guidance
Watch and wait
2.5
Contraindicated (progression)
Drug therapy alone
Contraindicated (failure)
PAIR
12.5
4d to 6 months
3 weeks to 6 months
Contraindicated (recurrence)
Other percutaneous intervention (PEVAC) 10
1 week to 1 month
1 month to 6 months
With drug cover (length not specified)
Surgery
62.5
0-6 months
1month to 1 year
With drug cover (1 day pre to 1month post)
Other
Further investigation

8. Patient 2 33 year old M Left lobectomy 1990 with 6 months BMZ
2010: malaise, vomiting
Hydatid IgG positive
KEY CONCERN
Wide variation in drug doses
Treatment length: 6 weeks to life long
Increasing use of Praziquantel
Interval dosing Albendazole
Drug
% used
Dose range
Expert Consensus dose
Albendazole
64.7
400mg OD/ BD
800mg OD
10-20 mg/kg/d
400mg BD for 6x 21day cycles
10-15mg/kg in two divided doses
Mebendazole
2.9
15mg/kg/d
40-50mg/kg in three divided doses
Praziquantel
Not recommended as a sole agent
Combination Albendazole and Praziquantel
29.4
100mg BD
6mg/kg/d
25-50 mg/kg/d
40mg/kg twice a week
2400mg STAT
10-15mg/kg Albendazole in two divided doses
40mg/kg Praziquantel once per week
No treatment
2.9 (surgery)

9. Patient 2 33 year old M Left lobectomy 1990 with 6 months BMZ
2010: malaise, vomiting
Hydatid IgG positive
KEY CONCERN
Wide variation in drug doses
Treatment length: 6 weeks to life long
Increasing use of Praziquantel
Interval dosing Albendazole
Drug
% used
Dose range
Expert Consensus dose
Albendazole
64.7
400mg OD/ BD
800mg OD
10-20 mg/kg/d
400mg BD for 6x 21day cycles
10-15mg/kg in two divided doses
Mebendazole
2.9
15mg/kg/d
40-50mg/kg in three divided doses
Praziquantel
Not recommended as a sole agent
Combination Albendazole and Praziquantel
29.4
100mg BD
6mg/kg/d
25-50 mg/kg/d
40mg/kg twice a week
2400mg STAT
10-15mg/kg Albendazole in two divided doses
40mg/kg Praziquantel once per week
No treatment
2.9 (surgery)

10. Patient 2 33 year old M Left lobectomy 1990 with 6 months BMZ
2010: malaise, vomiting
Hydatid IgG positive
KEY CONCERN
Wide variation in drug doses
Treatment length: 6 weeks to life long
Increasing use of Praziquantel
Interval dosing Albendazole
Drug
% used
Dose range
Expert Consensus dose
Albendazole
64.7
400mg OD/ BD
800mg OD
10-20 mg/kg/d
400mg BD for 6x 21day cycles
10-15mg/kg in two divided doses
Mebendazole
2.9
15mg/kg/d
40-50mg/kg in three divided doses
Praziquantel
Not recommended as a sole agent
Combination Albendazole and Praziquantel
29.4
100mg BD
6mg/kg/d
25-50 mg/kg/d
40mg/kg twice a week
2400mg STAT
10-15mg/kg Albendazole in two divided doses
40mg/kg Praziquantel once per week
No treatment
2.9 (surgery)

11. Patient 2 33 year old M Left lobectomy 1990 with 6 months BMZ
2010: malaise, vomiting
Hydatid IgG positive
KEY CONCERN
Wide variation in drug doses
Treatment length: 6 weeks to life long
Increasing use of Praziquantel
Interval dosing Albendazole
Drug
% used
Dose range
Expert Consensus dose
Albendazole
64.7
400mg OD/ BD
800mg OD
10-20 mg/kg/d
400mg BD for 6x 21day cycles
10-15mg/kg in two divided doses
Mebendazole
2.9
15mg/kg/d
40-50mg/kg in three divided doses
Praziquantel
Not recommended as a sole agent
Combination Albendazole and Praziquantel
29.4
100mg BD
6mg/kg/d
25-50 mg/kg/d
40mg/kg twice a week
2400mg STAT
10-15mg/kg Albendazole in two divided doses
40mg/kg Praziquantel once per week
No treatment
2.9 (surgery)

12. Patient 3 58 year old F Fever and abdominal pain Hydatid IgG positive
MRI: type 3A cyst involving diaphragm and lung base
KEY POINTS
No real guidance in Expert Consensus
PAIR contraindicated in lung disease
% used
Pre procedure BMZ therapy
Post procedure BMZ therapy
Expert consensus guidance
Watch and wait
Contraindicated (progression)
Drug therapy alone
Contraindicated (failure)
PAIR
20.6
3 days to 1 month
1 month to 1 year
Contraindicated (lung involvement)
Other percutaneous intervention
5.9
4 hours- 1 week
1month to 6 months
Surgery
73.5
0 to 6 months
1 month to 6 months
No guidance

13. Patient 3 58 year old F Fever and abdominal pain Hydatid IgG positive
MRI: type 3A cyst involving diaphragm and lung base
KEY POINTS
No real guidance in Expert Consensus
PAIR contraindicated in lung disease
% used
Pre procedure BMZ therapy
Post procedure BMZ therapy
Expert consensus guidance
Watch and wait
Contraindicated (progression)
Drug therapy alone
Contraindicated (failure)
PAIR
20.6
3 days to 1 month
1 month to 1 year
Contraindicated (lung involvement)
Other percutaneous intervention
5.9
4 hours- 1 week
1month to 6 months
Surgery
73.5
0 to 6 months
1 month to 6 months
No guidance

14. Patient 4 76 year old M, multiple co-morbidities
2 previous surgeries for CE.
Previous hepatitis with Albendazole
Now abdominal pain and eosinophilia
MRCP: hepatic hydatid cyst
ERCP: communication between cyst and biliary duct
KEY POINTS
Scolicidal agent used by 55%
Praziquantel as sole agent
Low dose Albendazole
% used
Watch and wait
3.6
Drug therapy alone
10.7
PAIR
Other percutaneous intervention
14.3
Surgery
71.5
Drug
% used
Dose
Albendazole 48
200mg OD – 400mg BD
Mebendazole 8
50mg/kg/d
Praziquantel 12
20-50mg/kg/d
Albendazole/ Praziquantel
200mg OD-400mg BD
25-50mg/kg/d
Nil 24

15. Patient 4 76 year old M, multiple co-morbidities
2 previous surgeries for CE.
Previous hepatitis with Albendazole
Now abdominal pain and eosinophilia
MRCP: hepatic hydatid cyst
ERCP: communication between cyst and biliary duct
KEY POINTS
Scolicidal agent used by 55%
Praziquantel as sole agent
Low dose Albendazole
% used
Watch and wait
3.6
Drug therapy alone
10.7
PAIR
Other percutaneous intervention
14.3
Surgery
71.5
Drug
% used
Dose
Albendazole 48
200mg OD – 400mg BD
Mebendazole 8
50mg/kg/d
Praziquantel 12
20-50mg/kg/d
Albendazole/ Praziquantel
200mg OD-400mg BD
25-50mg/kg/d
Nil 24

16. Patient 4 76 year old M, multiple co-morbidities
2 previous surgeries for CE.
Previous hepatitis with Albendazole
Now abdominal pain and eosinophilia
MRCP: hepatic hydatid cyst
ERCP: communication between cyst and biliary duct
KEY POINTS
Scolicidal agent used by 55%
Praziquantel as sole agent
Low dose Albendazole
% used
Watch and wait
3.6
Drug therapy alone
10.7
PAIR
Other percutaneous intervention
14.3
Surgery
71.5
Drug
% used
Dose
Albendazole 48
200mg OD – 400mg BD
Mebendazole 8
50mg/kg/d
Praziquantel 12
20-50mg/kg/d
Albendazole/ Praziquantel
200mg OD-400mg BD
25-50mg/kg/d
Nil 24

17. Patient 4 76 year old M, multiple co-morbidities
2 previous surgeries for CE.
Previous hepatitis with Albendazole
Now abdominal pain and eosinophilia
MRCP: hepatic hydatid cyst
ERCP: communication between cyst and biliary duct
KEY POINTS
Scolicidal agent used by 55%
Praziquantel as sole agent
Low dose Albendazole
% used
Watch and wait
3.6
Drug therapy alone
10.7
PAIR
Other percutaneous intervention
14.3
Surgery
71.5
Drug
% used
Dose
Albendazole 48
200mg OD – 400mg BD
Mebendazole 8
50mg/kg/d
Praziquantel 12
20-50mg/kg/d
Albendazole/ Praziquantel
200mg OD-400mg BD
25-50mg/kg/d
Nil 24

18. Patient 4 76 year old M, multiple co-morbidities
2 previous surgeries for CE.
Previous hepatitis with Albendazole
Now abdominal pain and eosinophilia
MRCP: hepatic hydatid cyst
ERCP: communication between cyst and biliary duct
KEY POINTS
Scolicidal agent used by 55%
Praziquantel as sole agent
Low dose Albendazole
% used
Watch and wait
3.6
Drug therapy alone
10.7
PAIR
Other percutaneous intervention
14.3
Surgery
71.5
Drug
% used
Dose
Albendazole 48
200mg OD – 400mg BD
Mebendazole 8
50mg/kg/d
Praziquantel 12
20-50mg/kg/d
Albendazole/ Praziquantel
200mg OD-400mg BD
25-50mg/kg/d
Nil 24

19. Conclusions Areas of concern Where next? PAIR - type 2, lung cysts
Albendazole
Variable doses
Unclear length of treatment
Interrupted regimens
Under treatment in disseminated disease
Lack of clarity over praziquantel use
Scolicidal agents in biliary fistulae
Where next?
European CE registry collecting prospective data
Clinical trials in particular areas
Length of albendazole treatment
Role of praziquantel
Surgery vs other percutaneous procedures for type 2/3Bs
Evidence based, more presciptive guidelines
Improved international co-operation: russia- lots of disease. No publications. Lots of unusual practices.
More prescriptive guidelines: current guidelines lack information on how long to treat for, role of praziquantel.
Evidence is not there but best guess of group of experts is better than best guess of individual physicians thus should be more prescriptive.
Global hydatid registry- to collect prospective data on patient groups
Clinical trials for particular clinical questions: namely length of albendazole treatment, role of praziquangel, surgery vs pevacs for type 2/3 b