Sandbox ID Central Nervous System

Lyme neuroborreliosis

Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines^[1]

Early neurologic disease

Cranial nerve palsy (adult)

Preferred regimen: Amoxicillin 500 mg PO tid for 14 (14–21) days OR Doxycycline 100 mg PO bid for 14 (14–21) days OR Cefuroxime 500 mg PO bid for 14 (14–21) days.
Alternative regimen: Azithromycin 500 mg PO qd for 7–10 days OR Clarithromycin 500 mg PO bid for 14–21 days(not for pregnant) OR Erythromycin 500 mg PO qid for 14–21 days.

Cranial nerve palsy (pediatric)

Preferred regimen: Amoxicillin 50 mg/kg/day PO in 3 divided doses (maximum, 500 mg per dose) for 14 (14–21) days OR Doxycycline (for children aged ≥ 8 years) 4 mg/kg/day PO in 2 divided doses (maximum, 100 mg per dose) for 14 (14–21) days OR Cefuroxime 30 mg/kg/day PO in 2 divided doses (maximum, 500 mg per dose) for 14 (14–21) days.
Alternative regimen: Azithromycin 10 mg/kg/day PO (maximum of 500 mg per day) for 7–10 days OR Clarithromycin 7.5 mg/kg PO bid (maximum of 500 mg per dose) for 14–21 days OR Erythromycin 12.5 mg/kg PO qid (maximum of 500 mg per dose) for 14–21 days.

Meningitis or radiculopathy (adult)

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (10–28) days.
Alternative regimen: Cefotaxime 2 g IV q8h for 14 (10–28) days OR Penicillin G 18–24 million U/day IV divided every 4 h for 14 (10–28) days.

Note: For nonpregnant adult patients intolerant of β-lactam agents, Doxycycline 200–400 mg/day PO/IV in 2 divided doses may be considered.

Meningitis or radiculopathy (pediatric)

Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (maximum, 2 g) for 14 (10–28) days.
Alternative regimen: Cefotaxime 150–200 mg/kg/day IV in 3–4 divided doses (maximum, 6 g per day) for 14 (10–28) days OR Penicillin G 200,000–400,000 U/kg/day IV divided every 4 h (not to exceed 18–24 million U per day) for 14 (10–28) days.

Note: For children 􏱢≥ 8 years of age intolerant of β-lactam agents, Doxycycline 4–8 mg/kg per day PO/IV in 2 divided doses (maximum daily dosage of 200–400 mg) may be considered.

Late neurologic disease

Central or peripheral nervous system disease (adult)

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (10–28) days.
Alternative regimen: Cefotaxime 2 g IV q8h for 14 (10–28) days OR Penicillin G 18–24 million U/day IV divided every 4 h for 14 (10–28) days.

Central or peripheral nervous system disease (pediatric)

Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (maximum, 2 g) for 14 (10–28) days.
Alternative regimen: Cefotaxime 150–200 mg/kg/day IV in 3–4 divided doses (maximum, 6 g per day) for 14 (10–28) days OR Penicillin G 200,000–400,000 U/kg/day IV divided every 4 h (not to exceed 18–24 million U per day) for 14 (10–28) days.

American Academy of Neurology (AAN) Practice Parameter^[2]

Meningitis

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day q4h for 14 days
Alternative regimen: Doxycycline 100–200 mg BID for 14 days
Pediatric dose: Ceftriaxone 50–75 mg/kg/day in 1 dose, max 2 g; Cefotaxime 150–200 mg/kg/day in 3–4 divided doses, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day divided q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day in 2 divided doses, max 200 mg/dayose

Any neurologic syndrome with CSF pleocytosis

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day q4h for 14 days
Alternative regimen: Doxycycline 100–200 mg BID for 14 days
Pediatric dose: Ceftriaxone 50–75 mg/kg/day in 1 dose, max 2 g; Cefotaxime 150–200 mg/kg/day in 3–4 divided doses, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day divided q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day in 2 divided doses, max 200 mg/dayose

Peripheral nervous system disease (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy; normal CSF)

Preferred regimen: Doxycycline 100–200 mg BID for 14 days
Alternative regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day q4h for 14 days
Pediatric dose: Doxycycline (≥ 8 y/o) 4–8 mg/kg/day in 2 divided doses, max 200 mg/dayose; Ceftriaxone 50–75 mg/kg/day in 1 dose, max 2 g; Cefotaxime 150–200 mg/kg/day in 3–4 divided doses, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day divided q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day in 2 divided doses, max 200 mg/dayose

Encephalomyelitis

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day q4h for 14 days
Pediatric dose: Ceftriaxone 50–75 mg/kg/day in 1 dose, max 2 g; Cefotaxime 150–200 mg/kg/day in 3–4 divided doses, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day divided q4h, max 18–24 MU/day

Encephalopathy

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day q4h for 14 days
Pediatric dose: Ceftriaxone 50–75 mg/kg/day in 1 dose, max 2 g; Cefotaxime 150–200 mg/kg/day in 3–4 divided doses, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day divided q4h, max 18–24 MU/day

Post-treatment Lyme syndrome

Preferred regimen: No antibiotics indicated; symptomatic management only

Encephalitis

Viruses

Adenovirus

Preferred regimen: supportive

B virus

prophylactic antiviral therapy after bite or scratch

Preferred regimen: Valacyclovir

established disease

Preferred regimen: Valacyclovir OR Acyclovir OR Ganciclovir

CMV

Preferred regimen: Ganciclovir AND foscarnet

Eastern equine encephalitis virus

Preferred regimen: supportive

EBV

Preferred regimen: supportive AND Corticosteroids

Hendra virus

Preferred regimen: supportive

HHV-6

Preferred regimen: Ganciclovir OR Foscarnet

HIV

Preferred regimen: HAART

HSV-1 and -2

Preferred regimen: Acyclovir

Influenza virus

Preferred regimen: Oseltamivir

Japanese encephalitis virus

Preferred regimen: supportive

JC virus

Preferred regimen: Reversal or control of immunosuppression AND HAART in patients with AIDS

La Crosse virus

Preferred regimen: supportive

Measles virus

life-threatening disease

Preferred regimen: Ribavirin

SSPE

Preferred regimen: Ribavirin intrathecal

Mumps virus

Preferred regimen: supportive

Murray Valley encephalitis virus

Preferred regimen: supportive

Nipah virus

Preferred regimen: supportive AND Ribavirin

Nonpolio enteroviruses

Preferred regimen: supportive AND Intraventricular γ-globulin (for chronic and/or severe disease)

Poliovirus

Preferred regimen: supportive

Powassan virus

Preferred regimen: supportive

Rabies virus

postxposure prophylaxis

Preferred regimen: rabies immunoglobulin AND vaccine

after onset of disease

Preferred regimen: supportive

Rubella virus

Preferred regimen: supportive

St. Louis encephalitis virus

Preferred regimen: supportive
Alternative regimen: IFN-a-2b

Tickborne encephalitis virus

Preferred regimen: supportive

Vaccinia

Preferred regimen: supportive ± Corticosteroids

Venezuelan equine encephalitis virus

Preferred regimen: supportive

VZV

Preferred regimen: Acyclovir ± Corticosteroids
Preferred regimen: Ganciclovir ± Corticosteroids

West Nile virus

Preferred regimen: supportive

Western equine encephalitis virus

Preferred regimen: supportive

Bacteria

Anaplasma phagocytophilum (human granulocytotrophic ehrlichiosis)

Preferred regimen: Doxycycline

Bartonella bacilliformis (Oroya fever)

Preferred regimen: Chloramphenicol OR Ciprofloxacin] OR Doxycycline OR Ampicillin OR trimethoprim-sulfamethoxazole

Bartonella henselae (Cat scratch disease)

Preferred regimen: Doxycycline OR Azithromycin ± Rifampin

Borrelia burgdorferi (Lyme disease)

preferred regimen: Ceftriaxone OR Cefotaxime OR Penicillin G

Coxiella burnetii (Q fever)

Preferred regimen: Doxycycline AND Fluoroquinolone AND Rifampin

Ehrlichia chaffeensis (human monocytotrophic ehrlichiosis)

Preferred regimen: Doxycycline

Listeria monocytogenes

Preferred regimen: Ampicillin OR Trimethoprim-sulfamethoxazole AND Gentamicin

Mycobacterium tuberculosis

with meningitis

Preferred regimen: Dexamethasone

without meningitis

Preferred regimen: Isoniazid OR Rifampin OR Pyrazinamide OR Ethambutol

Mycoplasma pneumoniae

Preferred regimen: Azithromycin OR Doxycycline OR Fluoroquinolone

Rickettsia rickettsii (Rocky Mountain spotted fever)

Preferred regimen: Doxycycline
Alternative regimen: Chloramphenicol

Treponema pallidum (syphilis)

preferred regimen: Ceftriaxone OR Penicillin G

Tropheryma whipplei (Whipple's disease)

Preferred regimen: Ceftriaxone for 2–4 weeks, followed by Trimethoprim-sulfamethoxazole OR Cefixime for 1–2 years

Fungi

Coccidioides

Preferred regimen: Fluconazole
Alternative regimen: Itraconazole OR Voriconazole OR Amphotericin B (intravenous and intrathecal)

Cryptococcus neoformans

Preferred regimen: Amphotericin B deoxycholate AND flucytosine for 2 weeks, followed by fluconazole for 8 weeks ORv Lipid formulation of amphotericin B AND flucytosine for 2 weeks, followed by fluconazole for 8 weeks OR Amphotericin B AND flucytosine for 6–10 weeks

Histoplasma capsulatum

Preferred regimen: Liposomal amphotericin B for 4–6 weeks, followed by itraconazole for at least 1 year and until resolution of CSF abnormalities

Protozoa

Acanthamoeba

Preferred regimen: Trimethoprim-sulfamethoxazole AND rifampin AND ketoconazole OR Fluconazole AND sulfadiazine AND pyrimethamine

Balamuthia mandrillaris

Preferred regimen: Azithromycin OR Clarithromycin AND pentamidine AND flucytosine AND fluconazole AND sulfadiazine AND thioridazine OR trifluoperazine

Naegleria fowleri

Preferred regimen: Amphotericin B (intravenous and intrathecal) AND rifampin AND azithromycin OR sulfisoxazole OR miconazole

Plasmodium falciparum

Preferred regimen: Quinine OR quinidine OR artesunate OR artemether
Alternative regimen: Atovaquone OR proguanil OR Exchange transfusion (less than 10% parasitemia or cere- bral malaria)

Toxoplasma gondii

Preferred regimen: Pyrimethamine AND Sulfadiazine OR Clindamycin [[and}} Pyrimethamine
Alternative regimen (1): Trimethoprim-sulfamethoxazole
Alternative regimen (2): Pyrimethamine AND atovaqone OR Pyrimethamine AND clarithromycin OR Pyrimethamine AND azithromycin OR Pyrimethamine AND dapsone

Trypanosoma brucei gambiense (West African trypanosomiasis)

Preferred regimen: Eflornithine OR Melarsoprol

Trypanosoma brucei rhodesiense (East African trypanosomiasis)

Preferred regimen: Melarsoprol

Helminths

Baylisascaris procyonis

Preferred regimen: Corticosteroids
Alternative regimen: Albendazole AND diethylcarbamazine

Gnathostoma

Preferred regimen: Albendazole OR Ivermectin

Taenia solium (cysticercosis)

Preferred regimen: Albendazole OR Corticosteroids
Alternative regimen: Praziquantel

Prion

Human transmissible spongiform encephalopathy

Preferred regimen: supportive

Epidural abscess

Condition_Or_Pathogen

Preferred regimen: DrugName Dosage_Duration OR DrugName Dosage_Duration
Alternative regimen: DrugName Dosage_Duration

Meningitis, bacteria

Streptococcus pneumoniae (adult)

Penicillin MIC

<0.1 μg/mL

Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day OR chloramphenicol 4-6g qid

0.1–1.0 μg/mL

Preferred regimen:
Alternative regimen:

≥2.0 μg/mL

Preferred regimen:
Alternative regimen:

Cefotaxime or ceftriaxone MIC ≥1.0 μg/mL

Preferred regimen:
Alternative regimen:

Streptococcus pneumoniae (pediatric)

Penicillin MIC

<0.1 μg/mL

Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day OR chloramphenicol 4-6g qid

0.1–1.0 μg/mL

Preferred regimen:
Alternative regimen:

≥2.0 μg/mL

Preferred regimen:
Alternative regimen:

Cefotaxime or ceftriaxone MIC ≥1.0 μg/mL

Preferred regimen:
Alternative regimen:

Neisseria meningitidis (adult)

Penicillin MIC

<0.1 μg/mL

Preferred regimen:
Alternative regimen:

0.1–1.0 μg/mL

Preferred regimen:
Alternative regimen:

Neisseria meningitidis (pediatric)

Penicillin MIC

<0.1 μg/mL

Preferred regimen:
Alternative regimen:

0.1–1.0 μg/mL

Preferred regimen:
Alternative regimen:

Listeria monocytogenes (adult)

Preferred regimen:
Alternative regimen:

Listeria monocytogenes (pediatric)

Preferred regimen:
Alternative regimen:

Streptococcus agalactiae (adult)

Preferred regimen:
Alternative regimen:

Streptococcus agalactiae (pediatric)

Preferred regimen:
Alternative regimen:

Escherichia coli and other Enterobacteriaceae (adult)

Preferred regimen:
Alternative regimen:

Escherichia coli and other Enterobacteriaceae (pediatric)

Preferred regimen:
Alternative regimen:

Pseudomonas aeruginosa (adult)

Preferred regimen:
Alternative regimen:

Pseudomonas aeruginosa (pediatric)

Preferred regimen:
Alternative regimen:

Haemophilus influenzae (adult)

β-Lactamase negative

Preferred regimen:
Alternative regimen:

β-Lactamase positive

Preferred regimen:
Alternative regimen:

Haemophilus influenzae (pediatric)

β-Lactamase negative

Preferred regimen:
Alternative regimen:

β-Lactamase positive

Preferred regimen:
Alternative regimen:

Staphylococcus aureus (adult)

Methicillin susceptible

Preferred regimen:
Alternative regimen:

Methicillin resistant

Preferred regimen:
Alternative regimen:

Staphylococcus aureus (pediatric)

Methicillin susceptible

Preferred regimen:
Alternative regimen:

Methicillin resistant

Preferred regimen:
Alternative regimen:

Staphylococcus epidermidis (adult)

Preferred regimen:
Alternative regimen:

Staphylococcus epidermidis (pediatric)

Preferred regimen:
Alternative regimen:

Enterococcus species (adult)

Ampicillin susceptible

Preferred regimen:
Alternative regimen:

Ampicillin resistant

Preferred regimen:
Alternative regimen:

Ampicillin and vancomycin resistant

Preferred regimen:
Alternative regimen:

References

↑ Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.
↑ Halperin, J. J.; Shapiro, E. D.; Logigian, E.; Belman, A. L.; Dotevall, L.; Wormser, G. P.; Krupp, L.; Gronseth, G.; Bever, C. T.; Quality Standards Subcommittee of the American Academy of Neurology (2007-07-03). "Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 69 (1): 91–102. doi:10.1212/01.wnl.0000265517.66976.28. ISSN 1526-632X. PMID 17522387.

[1] Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.

[2] Halperin, J. J.; Shapiro, E. D.; Logigian, E.; Belman, A. L.; Dotevall, L.; Wormser, G. P.; Krupp, L.; Gronseth, G.; Bever, C. T.; Quality Standards Subcommittee of the American Academy of Neurology (2007-07-03). "Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 69 (1): 91–102. doi:10.1212/01.wnl.0000265517.66976.28. ISSN 1526-632X. PMID 17522387.

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