How to manage a 6-year-old with OCD and intrusive thoughts following a strep infection, currently on Augmentin and prednisolone, with a history of similar symptoms resolving with antibiotics and steroids?

From the Guidelines

The current treatment with Augmentin and prednisolone should be continued as prescribed, and the full antibiotic course should be completed even if symptoms improve, as this appears to be a case of PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). The patient's history of similar symptoms resolving with antibiotics and steroids, such as cefdinir and prednisolone, suggests a potential autoimmune response triggered by the strep infection 1. The fact that the symptoms started to improve with prednisolone, but the improvement faded after 4 hours, indicates that the steroid is having a positive effect, but the dosage may need to be adjusted or the treatment duration extended.

Given the patient's weight of 40lbs, the current dosage of Augmentin and prednisolone should be reviewed to ensure it is appropriate. According to the guidelines, the recommended dosage for amoxicillin (a component of Augmentin) is 50 mg/kg once daily, with a maximum of 1000 mg per day 1. The patient's current dosage of Augmentin should be verified to ensure it is within the recommended range.

In addition to continuing the current treatment, it is essential to contact the child's doctor to discuss the possibility of a PANDAS/PANS diagnosis and consider referral to a specialist with experience in these conditions. Providing emotional support and reassurance to the child about their intrusive thoughts, avoiding punishment for OCD behaviors, and using simple cognitive-behavioral techniques like "boss back" strategies can also help manage the symptoms.

Keeping a symptom diary to track behaviors, triggers, and medication effects will be helpful in monitoring the patient's progress and adjusting the treatment plan as needed. The connection between strep infections and sudden-onset OCD symptoms is thought to be due to an autoimmune response where antibodies mistakenly attack brain tissue, particularly the basal ganglia, which regulates movement and behavior 1. This explains why antibiotics and anti-inflammatory medications like prednisolone often help reduce symptoms by addressing both the infection and inflammation.

Key points to consider:

• Continue current treatment with Augmentin and prednisolone as prescribed
• Complete the full antibiotic course even if symptoms improve
• Review and adjust the dosage of Augmentin and prednisolone as needed based on the patient's weight and response to treatment
• Consider referral to a specialist with experience in PANDAS/PANS
• Provide emotional support and reassurance to the child
• Use cognitive-behavioral techniques to manage OCD symptoms
• Keep a symptom diary to track progress and adjust treatment plan as needed.

From the FDA Drug Label

The initial dose of prednisolone sodium phosphate oral solution, (15 mg prednisolone base) may vary from 1.67 mL to 20 mL (5 to 60 mg prednisolone base) per day depending on the specific disease entity being treated. In pediatric patients, the initial dose of prednisolone sodium phosphate oral solution may vary depending on the specific disease entity being treated. The range of initial doses is 0.14 to 2 mg/kg/day in three or four divided doses (4 to 60 mg/m2bsa/day).

The patient is currently taking 3 ml of prednisolone daily, which seems to be effective but with a short duration of action. Considering the patient's weight (40lbs) and the dosage range for pediatric patients (0.14 to 2 mg/kg/day), the current dose appears to be within the recommended range.

• The patient's symptoms started to improve with prednisolone, but the improvement faded after about 4 hours post-dose.
• The dosage may need to be adjusted to achieve a more sustained response.
• It is essential to monitor the patient's response and adjust the dosage accordingly, as the dosage requirements are variable and must be individualized.
• The patient is also on Augmentin (amoxicillin/clavulanate), and it is crucial to continue monitoring for potential side effects and interactions between the two medications 2, 2, 3.

Given the patient's history and current symptoms, it would be prudent to consider the following options:

• Adjust the prednisolone dosage: Consider increasing the dose or frequency to achieve a more sustained response, while closely monitoring for potential side effects.
• Continue Augmentin: Complete the full course of antibiotics as prescribed, while monitoring for signs of infection or other adverse reactions.
• Monitor and reassess: Regularly evaluate the patient's symptoms and adjust the treatment plan as needed to ensure the best possible outcome.

From the Research

Management of OCD and Intrusive Thoughts in a 6-year-old following a Strep Infection

The patient is currently on Augmentin and prednisolone, with a history of similar symptoms resolving with antibiotics and steroids. Considering the patient's weight (40lbs) and the fact that symptoms started to improve on prednisolone, the following points are relevant:

• The patient is already on a course of antibiotics (Augmentin) and steroids (prednisolone), which is a common treatment approach for strep infections and associated psychiatric symptoms 4, 5.
• The use of prednisolone has shown some improvement in symptoms, but the effect fades after about 4 hours post-dose, suggesting that the current dosage may not be sufficient or the duration of action may be limited 6.
• Studies have shown that daily low-dose prednisolone can be effective in preventing relapse of steroid-sensitive nephrotic syndrome in children with upper respiratory tract infections 7, 8.
• However, the patient's condition is different, and the use of prednisolone in this context may require careful consideration of the dosage and duration of treatment.

Potential Next Steps

• Consider increasing the dosage of prednisolone or adjusting the treatment regimen to achieve a more sustained effect, while monitoring for potential side effects 6.
• Continue the course of antibiotics (Augmentin) to ensure complete eradication of the strep infection, as suggested by studies on the effectiveness of azithromycin in treating streptococcal infections 4, 5.
• Monitor the patient's symptoms and adjust the treatment plan as needed, taking into account the potential benefits and risks of continued steroid treatment 7, 8.
• Consider consulting with a specialist or seeking further guidance on the management of OCD and intrusive thoughts in children with a history of strep infections and steroid treatment.