Sandbox g23

Encephalitis

• Pathogen-directed antimicrobial therapy

• 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

• Preferred regimen: supportive

Note: Administer rabies immunoglobulin and vaccination for postxposure prophylaxis.

• 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