Sandbox ID Central Nervous System

Lyme neuroborreliosis

Further information: Lyme disease medical therapy and therapeutic approach

• Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines

• 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

• 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

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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

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Epidural abscess

Further information: Epidural abscess medical therapy and therapeutic approach

• Condition_Or_Pathogen

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