Sandbox g23

Encephalitis

• Empiric antimicrobial therapy

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

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

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

• Specific epidemiologic considerations

• 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 capsula- tum, 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, Ehr- lichia 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 — All agents transmitted by mosquitoes and ticks (see above), 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 en- cephalitis virus, Venezuelan equine encephalitis virus, St. Louis en- cephalitis 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 en- cephalitis 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

• Pathogen-directed antimicrobial therapy

• 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 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

• 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 10–15 mg/kg IV q8h for 10-14 days ± Corticosteroids
• Alternative 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