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__NOTOC__
{{Meningitis}}


{{CMG}}; {{AE}} {{CZ}}, {{SS}}
{{thymoma}}


==Empiric Therapy==


* If the suspected patient complaints with fever,headache,altered level of consciousness, signs of meningeal irritationthe, blood culture or CSF should be obtained urgently,then CT.But DO NOT wait for the results of the [[CT scan]] and the [[lumbar puncture]]; empiric treatment should be started as soon as possible.
==Thymic Tumor, Resectable <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''NCCN Guidelines: Thymomas and Thymic Carcinomas''<ref>{{Cite web  | last =  | first =  | title = https://www.nccn.org/store/login/login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/pdf/thymic.pdf | url = https://www.nccn.org/store/login/login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/pdf/thymic.pdf | publisher =  | date =  | accessdate = }}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
* Blood cultures should be drawn before starting the [[antibiotic]] therapy, and then the antibiotic treatment should be changed once the blood culture results are out.
* Empiric antibiotic treatment should be started within 30 minutes after the patient presentation.
* In case of high suspicion of pneumococcal meningitis in adult patients, 0.15 mg/kg IV Q6H dexomethasone should be administered for 2 to 4 days.
** The first dose of dexomethasone is given along with or 20 minutes prior to starting the antibiotics treatment.<ref name="pmid16394301">van de Beek D, de Gans J, Tunkel AR, Wijdicks EF (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16394301 Community-acquired bacterial meningitis in adults.] ''N Engl J Med'' 354 (1):44-53. [http://dx.doi.org/10.1056/NEJMra052116 DOI:10.1056/NEJMra052116] PMID: [http://pubmed.gov/16394301 16394301]</ref><ref name="pmid20417414">Edmond K, Clark A, Korczak VS, Sanderson C, Griffiths UK, Rudan I (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20417414 Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis.] ''Lancet Infect Dis'' 10 (5):317-28. [http://dx.doi.org/10.1016/S1473-3099(10)70048-7 DOI:10.1016/S1473-3099(10)70048-7] PMID: [http://pubmed.gov/20417414 20417414]</ref><ref name="pmid15494903">Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15494903 Practice guidelines for the management of bacterial meningitis.] ''Clin Infect Dis'' 39 (9):1267-84. [http://dx.doi.org/10.1086/425368 DOI:10.1086/425368] PMID: [http://pubmed.gov/15494903 15494903]</ref>


<div class="mw-collapsible mw-collapsed">
<B>
{{familytree/start}}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | | | | | | | | | | | | | A00 | |
A00=<div style="float: center; text-align: center; line-height: 42px; height: 84px; width: 84px; padding: 1px; font-size: 90%"><u>RESECTABLE</u> Thymic Tumor</div>}}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | | | | | | | | | | | | | |!| | | }}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | | | |,|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|.| | }}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | | | B01 | | | | | | | | B02 | | | | | | | | B03 | | |
B01=<div style="float: center; text-align: center; line-height: 42px; height: 84px; width: 84px; padding: 1px; font-size: 80%"> <u>NO</u> <BR> Residual Tumor</div>|
B02=<div style="float: center; text-align: center; line-height: 42px; height: 84px; width: 84px; padding: 1px; font-size: 80%"><u>MICROSCOPIC</u> <BR> Residual Tumor</div>|
B03=<div style="float: center; text-align: center; line-height: 42px; height: 84px; width: 84px; padding: 1px; font-size: 80%"><u>MACROSCOPIC</u> <BR> Residual Tumor</div>}}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | |,|-|^|-|.| | | | | |,|-|^|-|.| | | | | |,|-|^|-|.| | }}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | D01 | | D02 | | | | D03 | | D04 | | | | D05 | | D06 | |
D01=<div style="float: center; text-align: center; line-height: 84px; height: 84px; width: 84px; padding: 1px; font-size: 90%">Stage I</div>|
D02=<div style="float: center; text-align: center; line-height: 84px; height: 84px; width: 84px; padding: 1px; font-size: 90%">Stages II-IV</div>|
D03=<div style="float: center; text-align: center; line-height: 84px; height: 84px; width: 84px; padding: 1px; font-size: 90%">Thymoma</div>|
D04=<div style="float: center; text-align: center; line-height: 42px; height: 84px; width: 84px; padding: 1px; font-size: 90%">Thymic Carcinoma</div>|
D05=<div style="float: center; text-align: center; line-height: 84px; height: 84px; width: 84px; padding: 1px; font-size: 90%">Thymoma</div>|
D06=<div style="float: center; text-align: center; line-height: 42px; height: 84px; width: 84px; padding: 1px; font-size: 90%">Thymic Carcinoma</div>}}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | |!| | | |!| | | | | |!| | | |!| | | | | |!| | | |!| | | }}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | |!| | | E02 | | | | E03 | | E04 | | | | E05 | | E06 | | | |
E02=<div style="float: center; text-align: center; line-height: 84px; height: 84px; width: 84px; padding: 1px; font-size: 90%">[[Thymoma treatment#Radiation Dose|RT]]</div>|
E03=<div style="float: center; text-align: center; line-height: 84px; height: 84px; width: 84px; padding: 1px; font-size: 90%">[[Thymoma treatment#Radiation Dose|RT]]</div>|
E04=<div style="float: center; text-align: center; line-height: 28px; height: 84px; width: 84px; padding: 1px; font-size: 90%">[[Thymoma treatment#Radiation Dose|RT]] <BR> + <BR> [[Thymoma treatment#Chemotherapy Regimens|Chemotherapy]]</div>|
E05=<div style="float: center; text-align: center; line-height: 28px; height: 84px; width: 84px; padding: 1px; font-size: 90%">[[Thymoma treatment#Radiation Dose|RT]] <BR> ± <BR> [[Thymoma treatment#Chemotherapy Regimens|Chemotherapy]]</div>|
E06=<div style="float: center; text-align: center; line-height: 28px; height: 84px; width: 84px; padding: 1px; font-size: 90%">[[Thymoma treatment#Radiation Dose|RT]] <BR> + <BR> [[Thymoma treatment#Chemotherapy Regimens|Chemotherapy]]</div>}}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | |!| | | |!| | | | | |!| | | |!| | | | | |!| | | |!| | | |}}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | |`|-|-|-|^|-|-|-|-|-|^|-|v|-|^|-|-|-|-|-|^|-|-|-|'| | | |}}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{Family tree |border=2|boxstyle=background: WhiteSmoke; | | | | | | | | | | | | | F01 | | | | | | | | | | | | | |
F01=<div style="float: center; text-align: center; line-height: 84px; height: 84px; width: 84px; padding: 1px; font-size: 90%">Surveillance<sup>†</sup></div>}}
{{familytree/end}}
</B>


=====Community-Acquired Meningitis=====


<div class="mw-collapsible-content">
''<SMALL><sup>†</sup> CT scan every 6 months for 2 years, then annually every 5 years for thymic carcinoma and every 10 years for thymoma.</SMALL>''


{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:32em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Newborn, Age <1 Week}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 100—150 mg/kg/day IV q8—12h'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q12h'''''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Newborn, Age 1—4 Weeks}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 150—200 mg/kg/day IV q6—8h'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸'''''[[Tobramycin]]2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Infant and Children}}''<sup>†</sup>
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <BR> to achieve serum trough concentrations of 15–20 μg/mL
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 225—300 mg/kg/day IV q6–8h''''' <BR>''OR''<BR>▸'''''[[Ceftriaxone]] 80—100 mg/kg/day IV q12–24h''''' <BR> <BR> <BR> <BR>
|-
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:32em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult, Age <50 Years}}<sup>†</sup>''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30–60 mg/kg/day IV q8–12h''''' <BR> to achieve serum trough concentrations of 15–20 μg/mL
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 8–12 g/day IV q4–6h'''''<BR> ''OR'' <BR>▸'''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult, Age >50 Years}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30–60 mg/kg/day IV q8–12h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 8–12 g/day IV q4–6h'''''<BR> ''OR'' <BR>▸'''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Immunocompromised}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30–60 mg/kg/day IV q8–12h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h''''' <BR> ''OR'' <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Recurrent}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30—60 mg/kg/day IV q8–12h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]]  8–12 g/day IV q4–6h'''''<BR> ''OR'' <BR>▸'''''[[Ceftriaxone]] 2 g IV q12h'''''
|}
|}
<sup>†</sup>Add '''''[[Ampicillin]] 2 g IV q4h''''' ('''''50 mg/kg IV q6h''''' for children) if meningitis caused by ''[[Listeria monocytogenes]]'' is also suspected.
</div></div>
<div class="mw-collapsible mw-collapsed">
=====Healthcare-Associated Meningitis=====
<div class="mw-collapsible-content">
{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:32em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Basilar Skull Fracture}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30—60 mg/kg/day IV q8–12h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]]  8–12 g/day IV q4–6h'''''<BR> ''OR'' <BR> ▸'''''[[Ceftriaxone]] 2 g IV q12h'''''<BR><BR><BR>
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:32em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Head Trauma; Post-Neurosurgery}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30—60 mg/kg/day IV q8–12h'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime]]  2 g IV q8 h'''''<BR>''OR''<BR>▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR>''OR''<BR>▸ '''''[[Meropenem]] 2 g IV q8h'''''
|}
|}
<SMALL>Adapted from ''Advances in treatment of bacterial meningitis. Lancet. 2012;380(9854):1693-702.''</SMALL><ref name="van de Beek-2012">{{Cite journal  | last1 = van de Beek | first1 = D. | last2 = Brouwer | first2 = MC. | last3 = Thwaites | first3 = GE. | last4 = Tunkel | first4 = AR. | title = Advances in treatment of bacterial meningitis. | journal = Lancet | volume = 380 | issue = 9854 | pages = 1693-702 | month = Nov | year = 2012 | doi = 10.1016/S0140-6736(12)61186-6 | PMID = 23141618 }}</ref>
</div></div>
==Pathogen-Based Therapy==
<div class="mw-collapsible mw-collapsed">


=====''Streptococcus pneumoniae''=====
====Chemotherapy Regimens====


<div class="mw-collapsible-content">
<B><small>[[Thymoma treatment#Approach to Thymoma and Thymic Carcinoma|Return to top]]</small></B>


{|
{| {{table}}
| align="center" style="background:#f0f0f0;" colspan=2|'''FIRST-LINE COMBINATION CHEMOTHERAPY REGIMENS'''
| align="center" style="background:#f0f0f0;"|'''SECOND-LINE CHEMOTHERAPY'''
|-
|-
| valign=top |
| '''CAP''' (preferred for thymoma) <BR> * Cisplatin 50 mg/m² IV day 1  <BR> * Doxorubicin 50 mg/m² IV day 1 <BR>  * Cyclophosphamide 500 mg/m² IV day 1 <BR>  Administered every 3 weeks|| '''PE''' <BR> * Cisplatin 60 mg/m² IV day 1 <BR> *Etoposide 120 mg/m²/d IV days 1  -3 <BR> Administered every 3 weeks||rowspan=3 valign=top|Etoposide <BR> Ifosfamide <BR> Pemetrexed <BR> Octreotide (including LAR) + prednisone <BR> 5-FU and leucovirin <BR> Gemcitabine    <BR> Paclitaxel
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Penicillin]] MIC ≤0.06 μg/mL}}''
|-
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
| '''CAP with Prednisone'''  <BR>  * Cisplatin 30 mg/m² IV days 1-3 <BR> * Doxorubicin 20 mg/m²/d <BR> IV continuous infusion on days 1 to 3 <BR> * Cyclophosphamide 500 mg/m² IV on day 1 <BR> * Prednisone 100 mg/day on days 1-5 <BR> Administered every 3 weeks||'''VIP''' <BR> * Etoposide 75 mg/m² on days 1-4 <BR>* Ifosfamide 1.2 g/m² on days 1-4  <BR> * Cisplatin 20 mg/m² on days 1-4 <BR> Administered every 3  weeks
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] Low: 600,000–1.2 million units/day IM; High:≥ 20 million units IV q24h(=12 g)'''''<BR>''OR''<BR>▸ '''''[[Ampicillin]] 150–200 mg/kg IV q3-4h'''''
| '''ADOC''' <BR> * Cisplatin 50 mg/m² IV day 1 <BR> * Doxorubicin 40 mg/m² IV day 1  <BR> * Vincristine 0.6 mg/m² IV day 3  <BR> * Cyclophosphamide 700 mg/m² IV day 4 <BR> Administered every 3 weeks || '''Carboplatin/Paclitaxel''' (preferred for Thymic Carcinoma) <BR>* Carboplatin AUC 6 <BR> *  Paclitaxel 225 mg/m² <BR> Administered every 3 weeks
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''
|-
|-
|}
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Penicillin]] MIC ≥0.12 μg/mL}}''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Cefotaxime]] or [[Ceftriaxone]] MIC† <1.0 μg/mL}}
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd  (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<BR>''OR''<BR>▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Cefotaxime]] or [[Ceftriaxone]] MIC† >1.0 μg/mL}}
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ''AND''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h''''' <BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<sup>‡</sup>
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ''AND''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Moxifloxacin]] 400 mg po IV q24h '''''<sup>ɸ</sup>
|-
|}
|}
</div></div>
<div class="mw-collapsible mw-collapsed">
=====''Neisseria meningitidis''=====
<div class="mw-collapsible-content">
{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Neisseria meningitidis}}''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Penicillin]] MIC <0.1 μg/mL}}
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] Low: 600,000–1.2 million units/day IM; High:≥ 20 million units IV q24h(=12 g)'''''<BR>''OR''<BR>▸ '''''[[Ampicillin]] 0.25–0.5 g po q6h.150–200 mg/kg/day IV'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''<BR><BR><BR>
|-
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Neisseria meningitidis}}''
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Penicillin]] MIC ≥0.1 μg/mL}}
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''<BR>''OR''<BR>▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup><BR>''OR''<BR>▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
|}
|}
</div></div>
<div class="mw-collapsible mw-collapsed">
=====''Listeria monocytogenes'' and ''Streptococcus agalactiae''=====
<div class="mw-collapsible-content">
{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Listeria Monocytogenes}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 0.25–0.5 g po q6h.150–200 mg/kg/day IV'''''<BR>''OR''<BR>▸ '''''[[Penicillin G]] Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g)'''''<sup>£</sup>
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Trimethoprim-sulfamethoxazole]] 5–20 mg/kg/day q6-12h '''''
|-
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Streptococcus agalactiae}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 0.25–0.5 g po q6h.150–200 mg/kg/day IV'''''<BR>''OR''<BR>▸ '''''[[Penicillin G]] Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g)'''''<sup>£</sup>
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>
▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<BR>''OR''<BR>▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
|-
|}
|}
</div></div>
<div class="mw-collapsible mw-collapsed">
=====''Haemophilus influenzae''=====
<div class="mw-collapsible-content">
{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Haemophilus influenzae <BR> β-lactamase negative}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 0.25–0.5 g po q6h.150–200 mg/kg/day IV'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<BR>''OR''<BR>▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''<BR>''OR''<BR>▸ '''''[[Aztreonam]] 1 g IV q8h–2 g IV q6h'''''<BR>''OR''<BR>▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup>
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|β-lactamase negative, ampicillin resistant}}
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup>
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Haemophilus influenzae <BR> β-lactamase positive}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''<BR>''OR''<BR>▸ '''''[[Aztreonam]] 1 g q8h–2 g IV q6h'''''<BR>''OR''<BR>▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup>
|-
|}
|}
</div></div>
<div class="mw-collapsible mw-collapsed">
=====''Staphylococcus aureus''=====
<div class="mw-collapsible-content">
{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococcus aureus <BR> Meticillin sensitive}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 1–2 g IV/IM q4h<BR>''OR''<BR>▸ '''''[[Oxacillin]] 1–2 g IV/IM q4h
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''<BR>''OR''<BR>▸ '''''[[linezolid]] 600 mg IV/PO q12h<BR>''OR''<BR>▸ '''''[[Daptomycin]] 6 mg/kg IV q24h'''''
|-
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococcus aureus <BR> Meticillin resistant}}<sup>₦</sup>
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Trimethoprim-sulfamethoxazole]]  5–20 mg/kg/day q6-12h<BR>''OR''<BR>▸ '''''[[linezolid]] 600 mg IV/PO q12h<BR>''OR''<BR>▸ '''''[[Daptomycin]] 6 mg/kg IV q24h '''''<BR><BR><BR>
|-
|}
|}
</div></div>
<div class="mw-collapsible mw-collapsed">
=====''Staphylococcus epidermidis'' and ''Acinetobacter baumannii''<sup>Ω</sup>=====
<div class="mw-collapsible-content">
{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococcus epidermidis}}<sup>₦</sup>
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 600 mg IV/PO q12h<BR><BR><BR><BR><BR>
|-
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Acinetobacter baumannii}}
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Colistin]] <BR>in US:2.5-5 mg/kg/day q6-12h( 6.7-13.3 mg/kg/day of colistimethate sodium (CMS),max 800 mg/day); <BR>Elsewhere: ≤60 kg, 50,000-75,000 IU/kg/day IV q8h (=4-6 mg/kg per day of CMS). >60 kg, 1-2 mill IU IV q8h (= 80-160 mg IV tid).''''' <BR>''OR''<BR>▸ '''''[[Polymyxin B]] 15,000–25,000 units/kg/day q12h<sup>ǂ</sup>
|-
|}
|}
</div></div>
<div class="mw-collapsible mw-collapsed">
=====''Enterobacteriaceae'' and ''Pseudomonas aeruginosa''=====
<div class="mw-collapsible-content">
{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em; height: 25em;" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Enterobacteriaceae}}<sup>Ω</sup>
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 1 g q8h–2 g IV q6h''''' <BR> ''OR'' <BR> ▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup><BR> ''OR'' <BR> ▸ '''''[[Trimethoprim-sulfamethoxazole]] 5–20 mg/kg/day q6-12h''''' <BR> ''OR'' <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> ''OR'' <BR>▸ '''''[[Ampicillin]] 150–200 mg/kg/day IV'''''
|-
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em; height: 25em;" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pseudomonas aeruginosa}}''
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime ]] 1–2 g IV/IM q8–12h'''''<BR>''OR''<BR>▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<sup>£</sup>
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 1 g q8h–2 g IV q6h'''''<BR>''OR''<BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR>''OR''<BR> ▸ '''''[[Ciprofloxacin]] 500-750 mg po bid'''''<sup>£</sup><BR><BR><BR><BR><BR>
|-
|}
|}
<BR><SMALL><sup>†</sup> MIC = minimum inhibitory concentration.‡Addition of rifampicin can be considered if the organism is susceptible, the expected clinical or bacteriological response is delayed, or the cefotaxime/ceftriaxone MIC of the pneumococcal isolate is >4.0 μg/mL organism is susceptible, the expected clinical or bacteriological response is delayed, or the cefotaxime/ceftriaxone MIC.
<sup>Φ</sup> No clinical data exist for use of this agent in patients with pneumococcal meningitis; recommendation is based on cerebrospinal fluid penetration and in-vitro activity against S. pneumoniae.
<sup>£</sup> Addition of an aminoglycoside should be considered; might need intraventricular or intrathecal administration in Gram-negative meningitis.
<sup>ǁ</sup> Addition of rifampicin should be considered.
<sup>Ω</sup> Choice of a specific agent should be based on in-vitro susceptibility testing.
<sup>††</sup> Might also need to be administered by the intraventricular or intrathecal routes.
<sup>ǂ</sup> Might also need to be administered by the intraventricular or intrathecal routes.
<sup>₦</sup> Addition of rifampicin should be considered.


<sup>Δ</sup> The fluoroquinolones gatifloxacin and moxifloxacin pene trate the CSF effectively and have greater in-vitro activity against Gram-positive bacteria than do their earlier counterparts (eg, ciprofloxacin). Findings from experi mental meningitis models suggested their efficacy in S. pneumoniae meningitis, including that caused by penicillin-resistant and cephalosporin-resistant strains. Although one controlled trial suggested the fluoroquinolone trovafl -oxacin mesilate to be as eff  ective as ceftriaxone, with or without the addition of vancomycin, for paediatric bacterial meningitis, no clinical trials describe the use of gatifloxacin or moxifloxacin to treat bacterial meningitis in human beings. Trovafloxacin and gatifloxacin have been asso ciated with serious hepatic toxicity and dysglycaemia, respectively, and were with drawn from many markets. The IDSA guidelines recommend moxifloxacin as an alternative to third-generation cephalosporins plus vancomycin for meningitis caused by S. pneumoniae strains resistant to penicillin and third-generation cephalosporins, although some experts recom mend that this agent should not be used alone but rather should be combined with another drug (either vancomycin or a third-generation cephalosporin), because of the absence of clinical data supporting its use.
</SMALL>


</div></div>
====Radiation Dose====


==References==
<B><small>[[Thymoma treatment#Approach to Thymoma and Thymic Carcinoma|Return to top]]</small></B>
{{reflist|2}}


[[Category:Needs overview]]
* A dose of 60-70 Gy should be given to patients with unresectable disease.
[[Category:Primary care]]
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Neurology]]
[[Category:Emergency medicine]]
[[Category:Diseases involving the fasciae]]
[[Category:Inflammations]]
[[Category:Neurological disorders]]


{{WikiDoc Help Menu}}
* For adjuvant treatment, the radiation dose consists of 45-50 Gy for clear/close margins and 54 Gy for microscopically positive resection margins. A total dose of 60 Gy and above should be given to patients with gross residual disease (similar to patients with unresectable disease), when conventional fractionation (1.8 to 2.0 Gy per daily fraction) is applied.
{{WikiDoc Sources}}

Latest revision as of 03:34, 28 February 2014

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Thymic Tumor, Resectable Adapted from NCCN Guidelines: Thymomas and Thymic Carcinomas[1]

 
 
 
 
 
 
 
 
 
 
 
 
RESECTABLE Thymic Tumor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO
Residual Tumor
 
 
 
 
 
 
 
MICROSCOPIC
Residual Tumor
 
 
 
 
 
 
 
MACROSCOPIC
Residual Tumor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage I
 
Stages II-IV
 
 
 
Thymoma
 
Thymic Carcinoma
 
 
 
Thymoma
 
Thymic Carcinoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surveillance†
 
 
 
 
 
 
 
 
 
 
 
 
 


† CT scan every 6 months for 2 years, then annually every 5 years for thymic carcinoma and every 10 years for thymoma.


Chemotherapy Regimens

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FIRST-LINE COMBINATION CHEMOTHERAPY REGIMENS SECOND-LINE CHEMOTHERAPY
CAP (preferred for thymoma)
* Cisplatin 50 mg/m² IV day 1
* Doxorubicin 50 mg/m² IV day 1
* Cyclophosphamide 500 mg/m² IV day 1
Administered every 3 weeks		 PE
* Cisplatin 60 mg/m² IV day 1
*Etoposide 120 mg/m²/d IV days 1 -3
Administered every 3 weeks		 Etoposide
Ifosfamide
Pemetrexed
Octreotide (including LAR) + prednisone
5-FU and leucovirin
Gemcitabine
Paclitaxel
CAP with Prednisone
* Cisplatin 30 mg/m² IV days 1-3
* Doxorubicin 20 mg/m²/d
IV continuous infusion on days 1 to 3
* Cyclophosphamide 500 mg/m² IV on day 1
* Prednisone 100 mg/day on days 1-5
Administered every 3 weeks		 VIP
* Etoposide 75 mg/m² on days 1-4
* Ifosfamide 1.2 g/m² on days 1-4
* Cisplatin 20 mg/m² on days 1-4
Administered every 3 weeks
ADOC
* Cisplatin 50 mg/m² IV day 1
* Doxorubicin 40 mg/m² IV day 1
* Vincristine 0.6 mg/m² IV day 3
* Cyclophosphamide 700 mg/m² IV day 4
Administered every 3 weeks		 Carboplatin/Paclitaxel (preferred for Thymic Carcinoma)
* Carboplatin AUC 6
* Paclitaxel 225 mg/m²
Administered every 3 weeks


Radiation Dose

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  • A dose of 60-70 Gy should be given to patients with unresectable disease.
  • For adjuvant treatment, the radiation dose consists of 45-50 Gy for clear/close margins and 54 Gy for microscopically positive resection margins. A total dose of 60 Gy and above should be given to patients with gross residual disease (similar to patients with unresectable disease), when conventional fractionation (1.8 to 2.0 Gy per daily fraction) is applied.
  1. ↑ "https://www.nccn.org/store/login/login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/pdf/thymic.pdf" (PDF). External link in |title= (help)
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