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

Initial Treatment for PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections)

The initial treatment for a patient presenting with PANDAS should be antibiotics to eradicate the streptococcal infection, specifically penicillin or amoxicillin for 10 days. 1

First-Line Antibiotic Treatment Options

• Oral penicillin V (500 mg four times daily for 10 days) is a preferred first-line antibiotic for PANDAS 1
• Amoxicillin (500 mg three times daily for 10 days) is an equally effective alternative, often preferred for young children due to better taste acceptance 1, 2
• For penicillin-allergic patients, alternatives include:
  • Erythromycin (varies by formulation) 1, 2
  • Azithromycin (maximum dose of 500 mg once daily for 3-5 days) 1
  • Clindamycin (300 mg four times daily for 10 days) 1
• Intramuscular benzathine penicillin G should be considered for patients unlikely to complete oral therapy 1

Treatment Monitoring and Follow-up

• Post-treatment throat cultures are indicated only in patients who:
  • Remain symptomatic after treatment 1
  • Experience symptom recurrence 1
  • Have a history of rheumatic fever 1
• For treatment failures, consider:
  • Clindamycin 1, 3
  • Narrow-spectrum cephalosporins 1
  • Amoxicillin-clavulanic acid 1
  • Combination therapy with penicillin plus rifampin 1

Treatment Considerations for Severe or Persistent Cases

• For patients with severe neuropsychiatric symptoms or recurrent Group A Streptococcus-associated exacerbations, chronic secondary antimicrobial prophylaxis may be considered 3
• Antibiotics have shown some evidence of efficacy in reducing neuropsychiatric symptoms in PANDAS/PANS populations, even independent of ongoing infections 4
• Patient satisfaction has been associated with antibiotic treatment in PANDAS cases 5

Important Caveats and Limitations

• The American Heart Association notes that PANDAS should be considered only as a "yet-unproven hypothesis" 1
• Long-term antistreptococcal prophylaxis is not routinely recommended to prevent PANDAS 1
• Immunoregulatory therapies (e.g., IVIG, plasma exchange) are not recommended as first-line treatments 1, 6
• Despite clinical experience suggesting benefits, the evidence for all treatment options for PANDAS remains limited 5, 7
• Vigilance for other intercurrent infections, including sinusitis and influenza, is important as these may trigger symptom exacerbations 3

Diagnostic Considerations

• PANDAS is characterized by sudden-onset obsessive-compulsive symptoms and/or tics precipitated by streptococcal infection 1, 8
• Distinguishing PANDAS from typical OCD is important - PANDAS presents with abrupt symptom onset following streptococcal infection 8
• The condition may represent an autoimmune encephalopathy related to molecular mimicry, where antibodies against streptococcal antigens cross-react with brain tissue 6

While controversy exists regarding optimal management, the evidence most strongly supports initial antibiotic treatment to eradicate streptococcal infection as the first step in managing PANDAS, with careful monitoring and consideration of additional treatments for refractory cases.