Sandbox ID Central Nervous System

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Lyme neuroborreliosis

  • Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines[1]
  • Early neurologic disease
  • Cranial nerve palsy (adult)
  • 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[2]
  • 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
  • Encephalopathy
  • Post-treatment Lyme syndrome
  • Preferred regimen: symptomatic management; antibiotics not indicated

Encephalitis

  • Viruses
  • Preferred regimen: supportive
prophylactic antiviral therapy after bite or scratch
established disease
  • Preferred regimen: supportive
  • Preferred regimen: supportive
  • Preferred regimen: supportive
  • Preferred regimen: Reversal or control of immunosuppression AND HAART in patients with AIDS
  • Preferred regimen: supportive
life-threatening disease
SSPE
  • Preferred regimen: supportive
  • Preferred regimen: supportive
  • Preferred regimen: supportive AND Intraventricular γ-globulin (for chronic and/or severe disease)
  • Preferred regimen: supportive
  • Preferred regimen: supportive
postxposure prophylaxis
  • Preferred regimen: rabies immunoglobulin AND vaccine
after onset of disease
  • Preferred regimen: supportive
  • Preferred regimen: supportive
  • St. Louis encephalitis virus
  • Preferred regimen: supportive
  • Alternative regimen: IFN-a-2b
  • Tickborne encephalitis virus
  • Preferred regimen: supportive
  • Preferred regimen: supportive
  • Preferred regimen: supportive
  • Preferred regimen: supportive
  • Bacteria
  • Ehrlichia chaffeensis (human monocytotrophic ehrlichiosis)
with meningitis
without meningitis
  • Fungi
  • 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
  • Preferred regimen: Liposomal amphotericin B for 4–6 weeks, followed by itraconazole for at least 1 year and until resolution of CSF abnormalities
  • Protozoa
  • 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)
  • Helminths
  • Prion
  • Preferred regimen: supportive

Epidural abscess


Meningitis, bacteria

  • Streptococcus pneumoniae (adult)
  • Penicillin MIC
  • <0.1 μg/mL
  • 0.1–1.0 μg/mL
  • ≥2.0 μg/mL
  • Cefotaxime or ceftriaxone MIC ≥1.0 μg/mL


  • Streptococcus pneumoniae (pediatric)
  • Penicillin MIC
  • <0.1 μg/mL
  • Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
  • Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children
  • 0.1–1.0 μg/mL
  • Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
  • Alternative regimen: Cefepime 150 mg/kg tid for children OR meropenem 120 mg/kg tid for children
  • ≥2.0 μg/mL
  • Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND Ceftriaxone 80–100 mg/kg bid/OD for children OR Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
  • Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
  • Cefotaxime or ceftriaxone MIC ≥1.0 μg/mL
  • Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND Ceftriaxone 80–100 mg/kg bid/OD for children OR Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
  • Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD


  • Neisseria meningitidis (adult)
  • Penicillin MIC
  • <0.1 μg/mL
  • 0.1–1.0 μg/mL


  • Neisseria meningitidis (pediatric)
  • Penicillin MIC
  • <0.1 μg/mL
  • Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
  • Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
  • 0.1–1.0 μg/mL
  • Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
  • Alternative regimen: chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 120 mg/kg tid for children


  • Listeria monocytogenes (adult)
  • Listeria monocytogenes (pediatric)
  • Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
  • Alternative regimen: Trimethoprim-sulfamethoxazole10–20 mg/kg bid-qid for children {{or]} meropenem 120 mg/kg tid for children
  • Streptococcus agalactiae (adult)
  • Streptococcus agalactiae (pediatric)
  • Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
  • Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children


  • Escherichia coli and other Enterobacteriaceae (adult)
  • Escherichia coli and other Enterobacteriaceae (pediatric)
  • Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
  • Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 120 mg/kg tid for children OR Trimethoprim-sulfamethoxazole10–20 mg/kg bid-qid for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
  • Pseudomonas aeruginosa (adult)
  • Pseudomonas aeruginosa (pediatric)
  • Preferred regimen: Cefepime 150 mg/kg tid for children OR ceftazidime 100–150 mg/kg tid/bid for 0-7 days neonates; 150 mg/kg tid for 8-28 days neonates; 150 mg/kg tid for children
  • Alternative regimen: meropenem 120 mg/kg tid for children


  • Haemophilus influenzae (adult)
  • β-Lactamase negative
  • β-Lactamase positive
  • Haemophilus influenzae (pediatric)
  • β-Lactamase negative
  • Preferred regimen:ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
  • Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children OR Cefepime 150 mg/kg tid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
  • β-Lactamase positive
  • Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
  • Alternative regimen: Cefepime 150 mg/kg tid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
  • Staphylococcus aureus (adult)
  • Methicillin susceptible
  • Methicillin resistant
  • Staphylococcus aureus (pediatric)
  • Methicillin susceptible
  • Preferred regimen: Nafcillin 75 mg/kg bid/tid for 0-7 days neonates; 100–150 mg/kg tid/qid for 8-28 days neonates; 200 mg/kg qid for children OR oxacillin 75 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 200 mg/kg qid for children
  • Alternative regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children OR meropenem 120 mg/kg tid for children
  • Methicillin resistant
  • Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children
  • Alternative regimen: Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid for children OR linezolid


  • Staphylococcus epidermidis (adult)
  • Preferred regimen: Vancomycin
  • Alternative regimen: Linezolid
  • Staphylococcus epidermidis (pediatric)
  • Preferred regimen:
  • Alternative regimen:


  • Enterococcus species (adult)
  • Ampicillin susceptible
  • Preferred regimen: Ampicillin plus gentamicin
  • Ampicillin resistant
  • Preferred regimen: Vancomycin plus gentamicin
  • Ampicillin and vancomycin resistant
  • Preferred regimen: Linezolid



References

  1. 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.
  2. 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.