Prophylaxis Plan for Preventing PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) in High-Risk Patients
Currently, routine prophylaxis for PANS is not recommended as there is insufficient evidence to support its use, and the concept of PANDAS/PANS should be considered only as a yet-unproven hypothesis. 1
Current Evidence on Prophylaxis
- The American Heart Association does not recommend long-term antistreptococcal prophylaxis to prevent PANDAS, as causal relationships between Group A Streptococcal (GAS) infections and PANDAS have not been firmly established 1
- A pilot study of penicillin prophylaxis for neuropsychiatric exacerbations failed to show efficacy in preventing symptom exacerbations, though this was attributed to inadequate streptococcal prophylaxis in the study design 2
- Systematic reviews indicate that rigorously conducted research regarding treatments for PANDAS is scarce, and published studies have a high risk of bias 3
Monitoring and Management Approach for High-Risk Patients
Infection Surveillance and Management
- Maintain vigilance for streptococcal pharyngitis or dermatitis in patients with suspected PANS and their close contacts 4
- Promptly diagnose and treat intercurrent infections according to standard guidelines, including sinusitis and influenza 4
- Consider an initial course of anti-streptococcal treatment for newly diagnosed PANS cases, though this is based on expert opinion rather than high-quality evidence 4
Immunization Recommendations
- Ensure patients receive standard immunizations according to recommended schedules 4
- Pay attention to vitamin D status and supplement as needed 4
Special Considerations for Specific Patient Groups
- For patients with PANDAS who have severe neuropsychiatric symptoms or recurrent GAS-associated exacerbations, some experts suggest chronic secondary antimicrobial prophylaxis, though evidence for this approach is limited 4
- Limited utility has been shown for interventions such as adenotonsillectomy and probiotics in preventing PANS recurrences 4
Assessment During Initial Onset or Exacerbations
- Perform thorough evaluation for potential infectious triggers during initial onset or neuropsychiatric exacerbations 4, 5
- Consider that PANS is an umbrella condition that encompasses PANDAS, with PANDAS specifically associated with streptococcal infection 6
Important Caveats and Limitations
- The diagnosis of PANS/PANDAS lacks disease-specific biomarkers and strong evidence for pathogenic causes 6
- The condition is challenging from a clinical perspective and spans multiple subspecialties including psychiatry, rheumatology, neurology, infectious diseases, immunology, and developmental-behavioral pediatrics 6
- Current evidence does not support routine prophylaxis, and treatment decisions should be based on individual clinical presentation and severity 5
Pitfalls to Avoid
- Avoid prescribing long-term antibiotic prophylaxis without clear evidence of benefit, as this may contribute to antimicrobial resistance 1
- Do not rely on immunoregulatory therapy (e.g., intravenous immunoglobulin, plasma exchange) for prevention, as these interventions lack sufficient evidence 1
- Recognize that PANDAS/PANS remains a controversial diagnosis with ongoing debate about etiology, diagnosis, and management 5