At a glance
- Treatment options for cystic echinococcosis include chemotherapy, cyst puncture, and PAIR (percutaneous aspiration, injection of chemicals and reaspiration).
- In some cases, no treatment but a conservative "watch and wait" approach is best.
- Alveolar echinococcosis requires chemotherapy with or without surgery.
Treatment options
Cystic Echinococcosis
In the past, surgery was the only treatment for cystic echinococcal cysts. Chemotherapy, cyst puncture, and PAIR (percutaneous aspiration, injection of chemicals and reaspiration) have been used to replace surgery as effective treatments for cystic echinococcosis and, for some cases, no treatment but a conservative "watch and wait" approach is best. Treatment indications vary with cyst characteristics, including cyst type, location, size, and complications. Surgery may be the best treatment for liver cysts that are secondarily infected, or cysts located in the brain, lungs, or kidney. Liver cysts larger than 7.5 cm are likely to have biliary communication; surgery may be the best option for these cysts. Many abdominal cysts can be treated by injection of protoscolicidal chemical solutions into the cyst, followed by evacuation, prior to further manipulations and extirpation of cysts.
For some patients, chemotherapy with benzimidazoles is the preferred treatment. Patients with small cysts or multiple cysts in several organs can be treated successfully with albendazole. Approximately one third of patients treated with chemotherapy with benzimidazole drugs have been cured of the disease and even higher proportions, between 30 – 50%, have responded with significant regression of the cyst size and alleviation of symptoms. Both albendazole 10 – 15 mg/kg body weight per day (max 800 mg orally in two doses) and, as a second choice for treatment, mebendazole 40 – 50 mg/kg body weight per day continuously for several months have been highly effective. Additionally, chemotherapy can be very effective when used in conjunction with surgery. Albendazole has been administered to patients prior to surgery for the intended purpose of facilitating the safe surgical manipulation of the cysts by inactivating protoscolices, altering the integrity of the cyst's membranes, and reducing the turgidity of the cysts. A third treatment option, PAIR (percutaneous aspiration, injection of chemicals and reaspiration), has been shown to be effective. This option is indicated for patients with relapse after surgery, failure of chemotherapy alone, or who refuse surgery.
Drug*
Adult Dosage
Pediatric Dosage
Albendazole
400 mg orally twice a day for 1-6 months
10-15 mg/kg/day (max 800 mg) orally in two doses for 1-6 months
*Praziquantel may be useful preoperatively or in case of spillage of cyst contents during surgery (Bygott JM, Chiodini PL. Acta Tropica 2009; 111: 95-101).
Oral albendazole and oral mebendazole are available for human use in the United States.
Alveolar Echinococcosis
Alveolar echinococcosis requires chemotherapy with or without surgery; radical surgery is the preferred approach in suitable cases. Effective treatment involves benzimidazoles administered continuously for at least two years and patient monitoring for 10 years or more since recurrence is possible. This has inhibited progression of alveolar echinococcosis and reduced lesion size in approximately half of treated cases. Intermittent treatment with albendazole is not recommended.
Resource
Care precautions
Treatment during pregnancy
Albendazole is a pregnancy category C drug. There are limited data on the use of albendazole in pregnant women. The available evidence suggests no difference in congenital abnormalities in the children of women accidentally treated with albendazole during mass drug administration (MDA) campaigns compared with those who were not. In MDA campaigns for which the World Health Organization (WHO) has determined that the benefits of treatment outweigh the risks, WHO allows use of albendazole in the 2nd and 3rd trimesters of pregnancy. However, healthcare providers should balance the risks of treatment for the fetus with the risks of disease progression in the woman in the absence of treatment.
Pregnancy Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal, or other) plus there are no controlled studies in women, or studies in women and animals are not available. Prescribe albendazole only if the potential benefits to the woman justify the potential risks to the fetus.
Treatment during lactation
Albendazole is minimally excreted in human milk. WHO has concluded that a single oral dose of albendazole can be given to lactating women.
Treatment in pediatric patients
The safety of albendazole in children less than 6 years old is not certain. Studies of the use of albendazole in children as young as one year old suggest that it is safe. According to WHO guidelines for MDA campaigns, children as young as one year of age (able to safely swallow tablets) can take albendazole. These campaigns have treated many children under six years old with albendazole, albeit at a reduced dose.
Treatment during pregnancy
Mebendazole is a pregnancy category C drug. Data on the use of mebendazole in pregnant women are limited. The available evidence suggests no difference in congenital anomalies in the children of women treated with mebendazole during mass drug administration (MDA) campaigns compared with those who were not. In MDA campaigns in countries where soil-transmitted helminths are common, World Health Organization (WHO) has determined that the benefits of treatment outweigh the risks and WHO allows use of mebendazole in the 2nd and 3rd trimesters of pregnancy. However, in a pregnant woman infected with a soil-transmitted helminth, balance the risks of treatment for the fetus with the risks of disease progression in the woman in the absence of treatment.
Pregnancy Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal, or other) plus there are no controlled studies in women, or studies in women and animals are not available. Prescribe mebendazole only if the potential benefits to the woman justify the potential risks to the fetus.
Treatment during lactation
Mebendazole is minimally excreted in breast milk. WHO classifies mebendazole as compatible with breastfeeding and allows its use in lactating women.
Treatment in pediatric patients
The safety of mebendazole in children is unclear. There are limited data in children under 2 years old. The WHO Model List of Essential Medicines for Children lists mebendazole as an intestinal antihelminthic medicine that can be used for children older than 2 years of age.