What is the initial treatment for a patient presenting with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal (PANDAS) infections?

Initial Treatment for PANDAS

The initial treatment for a patient presenting with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal (PANDAS) infections should be antibiotics to eradicate the streptococcal infection, specifically penicillin or amoxicillin for 10 days. 1, 2

Diagnostic Considerations

• PANDAS is characterized by sudden-onset obsessive-compulsive symptoms and/or tics precipitated by streptococcal infection 1, 3
• The condition remains a controversial diagnosis, with the American Heart Association noting that it should be considered only as a "yet-unproven hypothesis" 1
• Diagnostic criteria include:
  • Abrupt onset of OCD or tic disorder
  • Prepubertal age at onset
  • Association with group A streptococcal (GAS) infection
  • Neurological abnormalities during exacerbations
  • Episodic course of symptom severity 2, 4

First-Line Treatment: Antibiotics

• An initial course of anti-streptococcal treatment is recommended for all newly diagnosed PANDAS cases 2, 5

• Preferred antibiotic options include:

  • Oral penicillin V (500 mg four times a day for 10 days) 1
  • Amoxicillin (500 mg three times a day for 10 days) 1, 2
  • Intramuscular benzathine penicillin G for patients unlikely to complete oral therapy 1

• For penicillin-allergic patients:

  • Erythromycin is a suitable alternative 1
  • Clindamycin (300 mg four times a day for 10 days) may be used, especially for eradication failures 1
  • Azithromycin (maximum dose of 500 mg once a day for 3-5 days) 1

Treatment Monitoring and Follow-up

• Post-treatment throat cultures are indicated only in patients who:

  • Remain symptomatic
  • Experience symptom recurrence
  • Have a history of rheumatic fever 1

• For treatment failures:

  • Consider alternative antibiotics such as clindamycin, narrow-spectrum cephalosporins, or amoxicillin-clavulanic acid 1
  • Consider combination therapy with penicillin plus rifampin 1

Additional Treatment Considerations

• While antibiotics are the mainstay of initial treatment, some patients may require:

  • Cognitive behavioral therapy for OCD symptoms 5
  • Selective serotonin reuptake inhibitors (SSRIs) for persistent psychiatric symptoms 5
  • Non-steroidal anti-inflammatory drugs (NSAIDs) for inflammatory symptoms 5

• For severe or treatment-resistant cases, immunomodulatory therapies may be considered, though evidence is limited:

  • Intravenous immunoglobulin (IVIG) has been reported as effective in some cases 5, 4
  • Plasma exchange has been proposed but lacks strong evidence 1

Important Caveats

• The American Heart Association does not recommend:

  • Routine laboratory testing for GAS to diagnose PANDAS
  • Long-term antistreptococcal prophylaxis to prevent PANDAS
  • Immunoregulatory therapy (e.g., IVIG, plasma exchange) as first-line treatment 1

• Patient satisfaction is often higher with antibiotic treatment and correlates with overall clinical improvement 5

• Despite widespread clinical use, the evidence supporting antibiotic treatment specifically for PANDAS (beyond treating the acute infection) remains limited 6, 7

• Treatment decisions should be guided by the severity of symptoms and response to initial therapy, with recognition that this remains an area of ongoing research and debate 4, 7