Sandbox-ID-Central Nervous System: Difference between revisions

Revision as of 00:36, 8 June 2015

Central Nervous System

Brain abscess ⇧ Return to Top ⇧

Empiric antimicrobial therapy^[1]^[2]

Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.

Brain abscess in otherwise healthy patients

Preferred regimen: (Cefotaxime 8–12 g/day IV q4–6h OR Ceftriaxone 4 g/day IV q12h) AND Metronidazole 30 mg/kg/day IV q6h
Alternative regimen: Meropenem 6 g/day IV q8h

Brain abscess with comorbidities

Otitis media, mastoiditis, or sinusitis

Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h

Dental infection

Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h

Penetrating trauma or post-neurosurgy

Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h OR Cefepime 2 g IV q12h) AND Vancomycin 30–45 mg/kg/day q8–12h

Lung abscess, empyema, or bronchiectasis

Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h AND TMP-SMZ 10–20 mg/kg/day q6–12h

Bacterial endocarditis

Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h AND Gentamicin 5 mg/kg/day IV q8h

Congenital heart disease

Preferred regimen: Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h

Transplant recipients

Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h AND Voriconazole 8 mg/kg/day q12h AND (TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h)

Patients with HIV/AIDS

Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd

Staphylococcus aureus coverage

Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h

Mycobacterium tuberculosis coverage

Preferred regimen: Isoniazid 300 mg qd AND Rifampin 600 mg qd AND Pyrazinamide 15–30 mg qd AND Ethambutol 15 mg/kg/day qd

Pathogen-directed antimicrobial therapy^[3]^[4]^[5]

Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.

Bacteria

Actinomyces

Preferred regimen: Penicillin G 4 MU IV q4h
Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h

Bacteroides fragilis

Preferred regimen: Metronidazole 30 mg/kg/day IV q6h
Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h

Enterobacteriaceae

Preferred regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h
Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR TMP-SMZ 10–20 mg/kg/day q6–12h OR Ciprofloxacin 800–1200 mg/day IV q8–12h OR Meropenem 2 g IV q8h

Fusobacterium

Preferred regimen: Metronidazole 30 mg/kg/day q6h
Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h OR Meropenem 2 g IV q8h

Haemophilus

Preferred regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h
Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR TMP-SMZ 10–20 mg/kg/day q6–12h

Listeria monocytogenes

Preferred regimen: Ampicillin 12 g/day q4h OR Penicillin G 4 MU IV q4h
Alternative regimen: TMP-SMZ 10–20 mg/kg/day q6–12h

Nocardia

Preferred regimen: TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h
Alternative regimen: Meropenem 2 g IV q8h OR Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Amikacin 15 mg/kg/day IV q8h

Prevotella melaninogenica

Preferred regimen: Metronidazole 30 mg/kg/day q6h
Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h OR Meropenem 2 g IV q8h

Pseudomonas aeruginosa

Preferred regimen: Ceftazidime 6 g/day q8h OR Cefepime 6 g/day q8h
Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR Ciprofloxacin 800–1200 mg/day IV q8–12h OR Meropenem 2 g IV q8h

Staphylococcus aureus, methicillin-resistant (MRSA)

Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h OR Linezolid 10 mg/kg/dose PO/IV q8h

Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin.

Staphylococcus aureus, methicillin-susceptible (MSSA)

Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h
Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h

Streptococcus

Preferred regimen: Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h
Alternative regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Vancomycin 30–45 mg/kg/day IV q8–12h

Fungi

Aspergillus

Preferred regimen: Voriconazole 8 mg/kg/day q12h
Alternative regimen: Amphotericin B deoxycholate 0.6–1.0 mg/kg/day IV q24h OR Amphotericin B lipid complex 5 mg/kg/day IV q24h OR Itraconazole 400–600 mg/day IV q12h OR Posaconazole 800 mg/kg/day IV q6–12h

Candida

Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
Alternative regimen: Fluconazole 400–800 mg/day IV q24h

Cryptococcus neoformans

Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
Alternative regimen: Fluconazole 400–800 mg/day IV q24h

Mucorales

Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
Alternative regimen: Posaconazole 800 mg/kg/day IV q6–12h

Pseudallescheria boydii (Scedosporium apiospermum)

Preferred regimen: Voriconazole 8 mg/kg/day q12h
Alternative regimen: Itraconazole 400–600 mg/day IV q12h OR Posaconazole 800 mg/kg/day IV q6–12h

Protozoa

Toxoplasma gondii

Preferred regimen: Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd
Alternative regimen (1): Pyrimethamine 25–100 mg/day qd AND Clindamycin 2400–4800 mg/day IV q6h
Alternative regimen (2): Pyrimethamine 25–100 mg/day qd AND (Azithromycin 1200–1500 mg/day IV q24h OR Atovaquone 750 mg IV q6h OR Dapsone 100 mg PO q24h)
Alternative regimen (3): TMP-SMZ 10–20 mg/kg/day q6–12h

Cerebrospinal fluid shunt infection ⇧ Return to Top ⇧

Empiric antimicrobial therapy^[6]^[7]

Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h OR Meropenem 2 g IV q8h)

Pathogen-directed antimicrobial therapy^[8]^[9]

Enterococcus

Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) AND Gentamicin 1–1.7 mg/kg IV q8h

Gram-negative bacilli

Preferred regimen: Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h OR Meropenem 2 g IV q8h OR Aztreonam 2 g IV q6h

Propionibacterium acnes

Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) ± Gentamicin 1–1.7 mg/kg IV q8h

Staphylococcus, coagulase-negative

Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h ± Rifampin 600 mg IV/PO q24h

Staphylococcus aureus, methicillin-resistant (MRSA)

Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h ± Rifampin 600 mg IV/PO q24h

Staphylococcus aureus, methicillin-susceptible (MSSA)

Preferred regimen: (Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h) ± Rifampin 600 mg IV/PO q24h

Streptococcus agalactiae

Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) AND Gentamicin 1–1.7 mg/kg IV q8h

Fungi

Preferred regimen: Amphotericin B 0.6–1.0 mg/kg IV q24h OR Amphotericin B liposomal 5 mg/kg/day IV q24h

Encephalitis ⇧ Return to Top ⇧

Empiric antimicrobial therapy^[10]

Preferred regimen: Acyclovir 10 mg/kg IV q8h for 14–21 days

Note (1): Acyclovir should be initiated in all patients with suspected encephalitis, pending results of diagnostic studies.

Note (2): Other empiric antimicrobial agents should be administered on the basis of specific epidemiologic or clinical clues.

Specific epidemiologic considerations^[11]

Agammaglobulinemia — Enteroviruses, Mycoplasma pneumoniae
Age

Neonates — Herpes simplex virus type 2, cytomegalovirus, rubella virus, Listeria monocytogenes, Treponema pallidum, Toxoplasma gondii
Infants and children — Eastern equine encephalitis virus, Japanese encephalitis virus, Murray Valley encephalitis virus, influenza virus, La Crosse virus
Elderly persons — Eastern equine encephalitis virus, St. Louis encephalitis virus, West Nile virus, sporadic CJD, L. monocytogenes

Animal contact

Bats — Rabies virus, Nipah virus
Birds — West Nile virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, Cryptococcus neoformans (bird droppings)
Cats — Rabies virus, Coxiella burnetii, Bartonella henselae, T. gondii
Dogs — Rabies virus
Horses — Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, Hendra virus
Old World primates — B virus
Raccoons — Rabies virus, Baylisascaris procyonis
Rodents — Eastern equine encephalitis virus (South America), Venezuelan equine encephalitis virus, tickborne encephalitis virus, Powassan virus (woodchucks), La Crosse virus (chipmunks and squirrels), Bartonella quintana
Sheep and goats — C. burnetii
Skunks — Rabies virus
Swine — Japanese encephalitis virus, Nipah virus
White-tailed deer — Borrelia burgdorferi

Immunocompromised persons — Varicella zoster virus, cytomegalovirus, human herpesvirus 6, West Nile virus, HIV, JC virus, L. monocytogenes, Mycobacterium tuberculosis, C. neoformans, Coccidioides species, Histoplasma capsulatum, T. gondii

Ingestion

Raw or partially cooked meat — T. gondii
Raw meat, fish, or reptiles — Gnanthostoma species
Unpasteurized milk — Tickborne encephalitis virus, L. monocytogenes, C. burnetii

Insect contact

Mosquitoes — Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, West Nile virus, La Crosse virus, Plasmodium falciparum
Sandflies — Bartonella bacilliformis
Ticks — Tickborne encephalitis virus, Powassan virus, Rickettsia rickettsii, Ehrlichia chaffeensis, Anaplasma phagocytophilum, C. burnetii (rare), B. burgdorferi
Tsetse flies — Trypanosoma brucei gambiense, Trypanosoma brucei rhodesiense

Occupation

Exposure to animals — Rabies virus, C. burnetii, Bartonella species
Exposure to horses — Hendra virus
Exposure to Old World primates — B virus
Laboratory workers — West Nile virus, HIV, C. burnetii, Coccidioides species
Physicians and health care workers — Varicella zoster virus, HIV, influenza virus, measles virus, M. tuberculosis
Veterinarians — Rabies virus, Bartonella species, C. burnetii

Person-to-person transmission — Herpes simplex virus (neonatal), varicella zoster virus, Venezuelan equine encephalitis virus (rare), poliovirus, nonpolio enteroviruses, measles virus, Nipah virus, mumps virus, rubella virus, Epstein-Barr virus, human herpesvirus 6, B virus, West Nile virus (transfusion, transplantation, breast feeding), HIV, rabies virus (transplantation), influenza virus, M. pneumoniae, M. tuberculosis, T. pallidum

Recent vaccination — Acute disseminated encephalomyelitis

Recreational activities

Camping/hunting — Agents transmitted by mosquitoes and ticks
Sexual contact — HIV, T. pallidum
Spelunking — Rabies virus, H. capsulatum
Swimming — Enteroviruses, Naegleria fowleri

Season

Late summer/early fall — Agents transmitted by mosquitoes and ticks, enteroviruses
Winter — Influenza virus

Transfusion and transplantation — Cytomegalovirus, Epstein-Barr virus, West Nile virus, HIV, tickborne encephalitis virus, rabies virus, iatrogenic CJD, T. pallidum, A. phagocytophilum, R. rickettsii, C. neoformans, Coccidioides species, H. capsulatum, T. gondii

Travel

Africa — Rabies virus, West Nile virus, P. falciparum, T. brucei gambiense, T. brucei rhodesiense
Australia — Murray Valley encephalitis virus, Japanese encephalitis virus, Hendra virus
Central America — Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, P. falciparum, Taenia solium
Europe — West Nile virus, tickborne encephalitis virus, A. phagocytophilum, B. burgdorferi
India, Nepal — Rabies virus, Japanese encephalitis virus, P. falciparum
Middle East — West Nile virus, P. falciparum
Russia — Tickborne encephalitis virus
South America — Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, B. bacilliformis (Andes mountains), P. falciparum, T. solium
Southeast Asia, China, Pacific Rim — Japanese encephalitis virus, tickborne encephalitis virus, Nipah virus, P. falciparum, Gnanthostoma species, T. solium
Unvaccinated status — Varicella zoster virus, Japanese encephalitis virus, poliovirus, measles virus, mumps virus, rubella virus

Specific clinical considerations^[12]

General findings

Hepatitis — Coxiella burnetii
Lymphadenopathy — HIV, Epstein-Barr virus, cytomegalovirus, measles virus, rubella virus, West Nile virus, Treponema pallidum, Bartonella henselae and other Bartonella species, Mycobacterium tuberculosis, Toxoplasma gondii, Trypanosoma brucei gambiense
Parotitis — Mumps virus
Rash — Varicella zoster virus, B virus, human herpesvirus 6, West Nile virus, rubella virus, some enteroviruses, HIV, Rickettsia rickettsii, Mycoplasma pneumoniae, Borrelia burgdorferi, T. pallidum, Ehrlichia chaffeensis, Anaplasma phagocytophilum
Respiratory tract findings — Venezuelan equine encephalitis virus, Nipah virus, Hendra virus, influenza virus, adenovirus, M. pneumoniae, C. burnetii, M. tuberculosis, Histoplasma capsulatum
Retinitis — Cytomegalovirus, West Nile virus, B. henselae, T. pallidum
Urinary symptoms — St. Louis encephalitis virus

Neurologic findings

Cerebellar ataxia — Varicella zoster virus (children), Epstein-Barr virus, mumps virus, St. Louis encephalitis virus, Tropheryma whipplei, T. brucei gambiense
Cranial nerve abnormalities — Herpes simplex virus, Epstein-Barr virus, Listeria monocytogenes, M. tuberculosis, T. pallidum, B. burgdorferi, T. whipplei, Cryptococcus neoformans, Coccidioides species, H. capsulatum
Dementia — HIV, human transmissible spongiform encephalopathies (sCJD and vCJD), measles virus (SSPE), T. pallidum, T. whipplei
Myorhythmia — T. whipplei (oculomasticatory)
Parkinsonism — Japanese encephalitis virus, St. Louis encephalitis virus, West Nile virus, Nipah virus, T. gondii, T. brucei gambiense
Poliomyelitis-like flaccid paralysis — Japanese encephalitis virus, West Nile virus, tickborne encephalitis virus; enteroviruses (enterovirus-71, coxsackieviruses), poliovirus
Rhombencephalitis — Herpes simplex virus, West Nile virus, enterovirus 71, L. monocytogenes

Pathogen-directed antimicrobial therapy^[13]

Viruses

Adenovirus

Preferred regimen: supportive

B virus (herpes B virus)

Established disease

Preferred regimen: Valacyclovir 1,000 mg PO tid OR Ganciclovir 5 mg/kg IV q12h for ≥ 14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily indefinitely OR Valacyclovir 1 g PO tid indefinitely
Alternative regimen: Acyclovir 15 mg/kg IV q8h for ≥ 14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily OR Valacyclovir 1 g PO tid indefinitely

Prophylaxis after bite or scratch

Preferred regimen: Valacyclovir 1,000 mg PO tid

Cytomegalovirus (CMV)

Preferred regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance AND Foscarnet 90 mg/kg IV q12h for 14–21 days, followed by 90-120 mg/kg IV qd for maintenance

Eastern equine encephalitis virus

Preferred regimen: supportive

Epstein-Barr virus (EBV)

Preferred regimen: supportive ± Corticosteroids

Note: Acyclovir is not recommended.

Hendra virus

Preferred regimen: supportive

HSV-1 and HSV-2

Preferred regimen: Acyclovir 10 mg/kg IV q8h for 14–21 days
Preferred regimen (neonates): Acyclovir 20 mg/kg IV q8h for 21 days

Human herpesvirus 6 (HHV-6)

Preferred regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance OR Foscarnet 90 mg/kg IV q12h for 14–21 days, followed by 90-120 mg/kg IV qd for maintenance

Human immunodeficiency virus (HIV)

Preferred regimen: HAART

Influenza virus

Preferred regimen: Oseltamivir 75 mg PO bid

Japanese encephalitis virus

Preferred regimen: supportive

Note: Interferon alpha is not recommended.

JC virus

Preferred regimen: Reversal or control of immunosuppression OR 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

Alternative regimen: Ribavirin

Nonpolio enteroviruses

Preferred regimen: supportive

Note: Consider intraventricular γ-globulin for chronic and/or severe disease.

Poliovirus

Preferred regimen: supportive

Powassan virus

Preferred regimen: supportive

Rabies virus^[14]

Not previously vaccinated

Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
Preferred regimen (2): Human rabies immune globulin (HRIG) 20 IU/kg
Preferred regimen (3): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14

Previously vaccinated

Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
Preferred regimen (2): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0 and 3

Note: If anatomically feasible, the full dose of HRIG should be infiltrated around and into the wounds, and any remaining volume should be administered at an anatomical site intramuscularly distant from vaccine administration. In addition, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered.

Rubella virus

Preferred regimen: supportive

St. Louis encephalitis virus

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

Tickborne encephalitis virus

Preferred regimen: supportive

Vaccinia

Preferred regimen: supportive ± Corticosteroids (if suggestive of post-immunization)

Venezuelan equine encephalitis virus

Preferred regimen: supportive

Varicella zoster virus (VZV)

Preferred regimen: Acyclovir 10–15 mg/kg IV q8h for 10–14 days ± Corticosteroids
Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance ± 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, Carrion's disease)

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 AND Gentamicin
Alternative regimen: Trimethoprim-Sulfamethoxazole

Mycobacterium tuberculosis

Preferred regimen: (Isoniazid AND Rifampin AND Pyrazinamide AND Ethambutol) ± Dexamethasone (if suggestive of meningitis)

Mycoplasma pneumoniae

Preferred regimen: Azithromycin OR Doxycycline OR Fluoroquinolone

Rickettsia rickettsii (Rocky Mountain spotted fever)

Preferred regimen: Doxycycline
Alternative regimen: Chloramphenicol (for pregnant patients)

Treponema pallidum (syphilis)

Preferred regimen: Penicillin G
Alternative regimen: Ceftriaxone

Tropheryma whipplei (Whipple's disease)

Preferred regimen: Ceftriaxone for 2–4 weeks, followed by Trimethoprim-Sulfamethoxazole for 1–2 years 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 (1): Amphotericin B deoxycholate AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
Preferred regimen (2): Amphotericin B lipid complex AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
Preferred regimen (3): Amphotericin B deoxycholate AND Flucytosine for 6–10 weeks, followed by Fluconazole for 8 weeks

Note: Consider placement of lumbar drain or VP shunt.

Histoplasma capsulatum

Preferred regimen: Amphotericin B liposomal for 4–6 weeks, followed by Itraconazole for at least 1 year and until resolution of CSF abnormalities

Protozoa

Acanthamoeba

Preferred regimen (1): Trimethoprim-Sulfamethoxazole AND Rifampin AND Ketoconazole
Preferred regimen (2): 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 (1): Atovaquone-Proguanil
Alternative regimen (2): Exchange transfusion (for > 10% parasitemia or cerebral malaria)

Toxoplasma gondii

Preferred regimen: Pyrimethamine AND Sulfadiazine OR Clindamycin
Alternative regimen (1): Trimethoprim-sulfamethoxazole
Alternative regimen (2): Pyrimethamine AND (Atovaquone OR Clarithromycin OR Azithromycin OR 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: Albendazole AND Diethylcarbamazine AND Corticosteroids

Gnathostoma

Preferred regimen: Albendazole OR Ivermectin

Taenia solium (cysticercosis)

Preferred regimen: Albendazole AND Corticosteroids
Alternative regimen: Praziquantel AND Corticosteroids

Prion

Human transmissible spongiform encephalopathy

Preferred regimen: supportive

Epidural abscess ⇧ Return to Top ⇧

Spinal epidural abscess^[15]^[16]^[17]^[18]

Empiric antimicrobial therapy

Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks AND Ceftriaxone 2 g Iv q24h for 2–4 weeks, then PO to complete 6–8 weeks

Note (1): Decompressive laminectomy in conjunction with long-term antibiotic therapy tailored to culture results is required.

Note (2): For critically ill patients, a vancomycin loading dose of 20–25 mg/kg may be considered.

Pathogen-directed antimicrobial therapy

Penicillin-susceptible Staphylococcus aureus or Streptococcus

Preferred regimen: Penicillin G 4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks

Methicillin-susceptible Staphylococcus aureus or Streptococcus

Preferred regimen: Cefazolin 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks OR Nafcillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Oxacillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
Alternative regimen: Clindamycin 600 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks

Methicillin-resistant Staphylococcus aureus (MRSA)

Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks
Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h OR Linezolid 10 mg/kg/dose PO/IV q8h

Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin.

Streptococcus

Preferred regimen: Penicillin G 3–4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Ampicillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks

Enterococcus

Preferred regimen: Penicillin G 3–4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Ampicillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks

Enterobacteriaceae

Preferred regimen: Ceftriaxone 1–2 g IV q12h for 2–4 weeks, then PO to complete 6–8 weeks OR Cefotaxime 2 g IV q6–8h for 2–4 weeks, then PO to complete 6–8 weeks

Gram-negative bacteria

Preferred regimen:Ceftazidime 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks OR Cefepime 2 g IV q12h for 2–4 weeks, then PO to complete 6–8 weeks
Alternative regimen: Ciprofloxacin 400 mg IV q12h for 2–4 weeks, then PO to complete 6–8 weeks {{or]] Levofloxacin 750 mg IV q24h for 2–4 weeks, then PO to complete 6–8 weeks OR Moxifloxacin 400 mg IV q24h for 2–4 weeks, then PO to complete 6–8 weeks

Anaerobes

Preferred regimen: Metronidazole 500 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks

Staphylococcus, Gram-negative bacteria, and anaerobes (mixed infection)

Preferred regimen: Ampicillin-Sulbactam 3 g IV q6h for 2–4 weeks, then PO to complete 6–8 weeks OR Ticarcillin-Clavulanate 3.1 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Piperacillin-Tazobactam 3.375 g IV q4–6h for 2–4 weeks, then PO to complete 6–8 weeks
Alternative regimen: Imipenem 500–1000 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks OR Meropenem 1–2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks

Lyme neuroborreliosis ⇧ Return to Top ⇧

Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines^[19]

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, max 500 mg/dose for 14 (14–21) days OR Doxycycline (for children aged ≥ 8 years) 4 mg/kg/day PO q12h, max 100 mg/dose for 14 (14–21) days OR Cefuroxime 30 mg/kg/day PO q12h, max 500 mg/dose for 14 (14–21) days
Alternative regimen: Azithromycin 10 mg/kg/day PO, max 500 mg/dose for 7–10 days OR Clarithromycin 7.5 mg/kg PO bid, max 500 mg/dose for 14–21 days OR Erythromycin 12.5 mg/kg PO aid, max 500 mg/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 MU/day IV q4h for 14 (10–28) days

Note: for nonpregnant adult patients intolerant of β-lactam agents, Doxycycline 200–400 mg/day PO/IV q12h may be considered.

Meningitis or radiculopathy (pediatric)

Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h, max 2 g/day for 14 (10–28) days
Alternative regimen: Cefotaxime 150–200 mg/kg/day IV in 3–4 divided doses, max 6 g/day for 14 (10–28) days OR Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day for 14 (10–28) days

Note: for children ≥ 8 years of age intolerant of β-lactam agents, Doxycycline 4–8 mg/kg/day PO/IV q12h, max 200–400 mg/day 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 MU/day IV q4h for 14 (10–28) days

Central or peripheral nervous system disease (pediatric)

Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h, max 2 g for 14 (10–28) days.
Alternative regimen: Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day for 14 (10–28) days OR Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day for 14 (10–28) days

American Academy of Neurology (AAN) Practice Parameter^[20]

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 IV q24h, max 2 g/day; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day

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 IV q4h for 14 days
Alternative regimen: Doxycycline 100–200 mg BID for 14 days
Pediatric dose: Ceftriaxone 50–75 mg/kg/day IV q24h, max 2 g; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day

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 IV q4h for 14 days
Pediatric dose: Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day; Ceftriaxone 50–75 mg/kg/day IV q24h, max 2 g/day; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day

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 IV q24h, max 2 g/day; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day IV 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 IV q24h, max 2 g/day; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day

Post-treatment Lyme syndrome

Preferred regimen: symptomatic management

Note: Antibiotic therapy is not indicated.

Meningitis, bacterial ⇧ Return to Top ⇧

Meningitis, MRSA ⇧ Return to Top ⇧

Meningitis, tuberculous ⇧ Return to Top ⇧

Septic thrombosis of cavernous or dural venous sinus ⇧ Return to Top ⇧

Septic thrombosis of cavernous or dural venous sinus, MRSA ⇧ Return to Top ⇧

Septic thrombosis of cavernous or dural venous sinus caused by MRSA^[21]

Preferred regimen: Vancomycin 15–20 mg/kg/dose IV q8–12h for 4–6 weeks
Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h OR Linezolid 10 mg/kg/dose PO/IV q8h

Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible.

Note (2): Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin.

Subdural empyema ⇧ Return to Top ⇧

↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.
↑ Tunkel, Allan R.; Hartman, Barry J.; Kaplan, Sheldon L.; Kaufman, Bruce A.; Roos, Karen L.; Scheld, W. Michael; Whitley, Richard J. (2004-11-01). "Practice guidelines for the management of bacterial meningitis". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 39 (9): 1267–1284. doi:10.1086/425368. ISSN 1537-6591. PMID 15494903.
↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
↑ Tunkel, Allan R.; Hartman, Barry J.; Kaplan, Sheldon L.; Kaufman, Bruce A.; Roos, Karen L.; Scheld, W. Michael; Whitley, Richard J. (2004-11-01). "Practice guidelines for the management of bacterial meningitis". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 39 (9): 1267–1284. doi:10.1086/425368. ISSN 1537-6591. PMID 15494903.
↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
↑ Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.
↑ Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.
↑ Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.
↑ Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.
↑ Rupprecht, Charles E.; Briggs, Deborah; Brown, Catherine M.; Franka, Richard; Katz, Samuel L.; Kerr, Harry D.; Lett, Susan M.; Levis, Robin; Meltzer, Martin I.; Schaffner, William; Cieslak, Paul R.; Centers for Disease Control and Prevention (CDC) (2010-03-19). "Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR-2): 1–9. ISSN 1545-8601. PMID 20300058.
↑ Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.
↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
↑ Darouiche, Rabih O. (2006-11-09). "Spinal epidural abscess". The New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 1533-4406. PMID 17093252.
↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.
↑ 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.
↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.

[1] Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.

[2] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[3] Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.

[4] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[5] Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.

[6] Tunkel, Allan R.; Hartman, Barry J.; Kaplan, Sheldon L.; Kaufman, Bruce A.; Roos, Karen L.; Scheld, W. Michael; Whitley, Richard J. (2004-11-01). "Practice guidelines for the management of bacterial meningitis". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 39 (9): 1267–1284. doi:10.1086/425368. ISSN 1537-6591. PMID 15494903.

[7] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[8] Tunkel, Allan R.; Hartman, Barry J.; Kaplan, Sheldon L.; Kaufman, Bruce A.; Roos, Karen L.; Scheld, W. Michael; Whitley, Richard J. (2004-11-01). "Practice guidelines for the management of bacterial meningitis". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 39 (9): 1267–1284. doi:10.1086/425368. ISSN 1537-6591. PMID 15494903.

[9] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[10] Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.

[11] Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.

[12] Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.

[13] Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.

[14] Rupprecht, Charles E.; Briggs, Deborah; Brown, Catherine M.; Franka, Richard; Katz, Samuel L.; Kerr, Harry D.; Lett, Susan M.; Levis, Robin; Meltzer, Martin I.; Schaffner, William; Cieslak, Paul R.; Centers for Disease Control and Prevention (CDC) (2010-03-19). "Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR-2): 1–9. ISSN 1545-8601. PMID 20300058.

[15] Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.

[16] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[17] Darouiche, Rabih O. (2006-11-09). "Spinal epidural abscess". The New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 1533-4406. PMID 17093252.

[18] Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.

[19] 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.

[20] 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.

[21] Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.

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@@ Line 329: / Line 329: @@
 ::::* Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
 ::::* Preferred regimen (2): Human rabies immune globulin (HRIG) 20 IU/kg
 ::::* Preferred regimen (3): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14
 :::* Previously vaccinated
 ::::* Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
 ::::* Preferred regimen (2): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0 and 3
 ::::: Note:  If anatomically feasible, the full dose of HRIG should be infiltrated around and into the wounds, and any remaining volume should be administered at an anatomical site intramuscularly distant from vaccine administration.  In addition, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered.