Sandbox-ID-Central Nervous System

Central Nervous System

Brain abscess ⇧ Return to Top ⇧

• Empiric antimicrobial therapy

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

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

• 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

• 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

• 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

• 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

• 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

• 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

• Chikungunya virus

• Preferred regimen: supportive

• 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

• Louping ill virus

• Preferred regimen: supportive

• Lymphocytic choriomeningitis virus (LCMV)

• Preferred regimen: supportive

• Me Tri virus

• Preferred regimen: supportive

• Measles virus

• Preferred regimen: supportive

Note: Ribavirin is not approved by the US Food and Drug Administration (FDA) for this indication, and such use should be considered experimental.

• Monkeypox virus

• Preferred regimen: supportive
• Alternative regimen: Cidofovir OR vaccinia immune globulin

• 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

• 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.

• Rocio virus

• Preferred regimen: supportive

• Rubella virus

• Preferred regimen: supportive

• Snowshoe hare virus

• Preferred regimen: supportive

• St. Louis encephalitis virus

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

• Tickborne encephalitis virus

• Preferred regimen: supportive

• Toscana 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

• 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

• 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

• 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 ⇧

xx

Meningitis, MRSA ⇧ Return to Top ⇧

xx

Meningitis, tuberculous ⇧ Return to Top ⇧

xx

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

• Septic thrombosis of cavernous or dural venous sinus

• Empiric antimicrobial therapy

• Preferred regimen: (Nafcillin 2 g IV q4h or Oxacillin 2 g IV q4h) AND (Ceftriaxone 2 g IV q12h or Cefotaxime 8–12 g/day IV q4–6h) AND Metronidazole 7.5 mg/kg IV q6h

Note (1): Vancomycin 30–45 mg/kg IV q8–12h could be substituted for nafcillin or oxacillin if the risk of MRSA is high.

Note (2): The optimal duration of therapy remains unclear. A 3– to 4–week course of treatment is usually recommended.

• Specific considerations

• Cavernous sinus

• Preferred regimen: Vancomycin 30–45 mg/kg IV q8–12h AND (Ceftriaxone 2 g IV q12h or Cefotaxime 8–12 g/day IV q4–6h) AND Metronidazole 7.5 mg/kg IV q6h

Note: Daptomycin 8–12 mg/kg IV q24h OR Linezolid 600 mg IV q12h could be considered for patients unable to tolerate vancomycin.

• Lateral sinus

• Preferred regimen: Cefepime 2 g IV q8h AND Metronidazole 500 mg IV q8h AND Vancomycin 15-20 IV mg/kg
• Alternative regimen: Meropenem 1-2 g IV q8h AND Linezolid 600 mg IV q12h

• Superior sagittal sinus

• Preferred regimen: Ceftriaxone 2 g IV q12h AND Vancomycin 15–20 mg/kg AND Dexamethasone
• Alternative regimen: Meropenem 1–2 g IV q8h AND Vancomycin 15–20 mg/kg AND Dexamethasone

• Pathogen-directed antimicrobial therapy

• Staphylococcus aureus, methicillin-resistant (MRSA)

• 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 ⇧

• Subdural empyema

• Causative pathogens

• More common

• Streptococcus milleri
• Other streptococci and enterococci
• Aerobic Gram-negative bacilli (Haemophilus influenzae, Proteus, Escherichia coli, Pseudomonas, Klebsiella, Acinetobacter, Salmonella, Morganella, Eikenella)
• No growth

• Less common

• Streptococcus pneumoniae
• Staphylococcus aureus, coagulase-negative staphylococci
• Anaerobic Gram-positive cocci (Veillonella, Peptostreptococcus, others)
• Anaerobic Gram-negative bacilli (Bacteroides, Fusobacterium, Prevotella)

• Empiric antimicrobial therapy

Note (1): The choice of antimicrobial agent should be based on Gram stain results and directed against the likely causative microorganisms in the specific clinical setting.

Note (2): Metronidazole is recommended if anaerobes are suspected. Metronidazole is not necessary for antianaerobic activity if Meropenem is used.

Note (3): For coverage of aerobic Gram-negative bacilli, empiric therapy with Cefepime, Ceftazidime, or Meropenem is appropriate.

Note (4): Depending on the clinical response, parenteral antimicrobial therapy should be administered for 3 to 4 weeks after drainage. Parenteral or oral therapy is frequently continued for up to a total of 6 weeks of therapy.

Note (5): A longer course of treatment (minimum of 6–8 weeks) may be required if the patient has accompanying osteomyelitis.

Note (6): Consider adjunctive medications including prophylactic anticonvulsants, corticosteroids, and mannitol if clinically indicated.

• Intracranial subdural empyema with unclear source of infection

• Preferred regimen: (Nafcillin 2 g IV q4h or Oxacillin 2 g IV q4h) AND (Ceftriaxone 2 g IV q12h or Cefotaxime 8–12 g/day IV q4–6h) AND Metronidazole 7.5 mg/kg IV q6h

Note: Vancomycin should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema associated with sinusitis or otitis media

• Preferred regimen: (Nafcillin 2 g IV q4h or Oxacillin 2 g IV q4h) AND (Ceftriaxone 2 g IV q12h or Cefotaxime 8–12 g/day IV q4–6h) AND Metronidazole 7.5 mg/kg IV q6h

Note: Vancomycin should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema after cranial trauma

• Preferred regimen: Nafcillin 2 g IV q4h or Oxacillin 2 g IV q4h

Note: Vancomycin should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema after neurosurgical procedures

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND Ceftazidime 2 g IV q8h

• Intracranial subdural empyema in neonates (usually associated with meningitis)

• Infants < 1 month

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h AND Cefotaxime 200 mg/kg/day IV q6h

• Infants 1–3 months

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h AND (Cefotaxime 200 mg/kg/day IV q6h OR Ceftriaxone 100 mg/kg/day IV q12h)

• Infants > 3 months

• Preferred regimen: Vancomycin 60 mg/kg/day IV q6h AND (Cefotaxime 200 mg/kg/day IV q6h OR Ceftriaxone 100 mg/kg/day IV q12h OR Cefepime 150 mg/kg/day IV q8h)

• Spinal subdural empyema

• Preferred regimen: Nafcillin 2 g IV q4h or Oxacillin 2 g IV q4h

Note: Vancomycin should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Pathogen-directed antimicrobial therapy

• 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.