Treatment of PANDAS
The first-line treatment for a child diagnosed with PANDAS is antibiotic therapy to eradicate the streptococcal infection, specifically penicillin V (500 mg four times daily for 10 days) or amoxicillin (500 mg three times daily for 10 days). 1, 2
Initial Antibiotic Treatment
Preferred antibiotic regimens include:
- Penicillin V: 500 mg orally four times daily for 10 days 1, 2
- Amoxicillin: 500 mg orally three times daily for 10 days (equally effective alternative, often preferred in young children due to better taste acceptance) 1, 2
- Intramuscular benzathine penicillin G: For patients unlikely to complete oral therapy 1
For penicillin-allergic patients:
- Erythromycin is a suitable alternative 1, 2
- Azithromycin: Maximum dose of 500 mg once daily for 3-5 days 1, 2
- Clindamycin: 300 mg four times daily for 10 days, especially useful for eradication failures 1, 2
The rationale for antibiotic treatment is to eradicate the streptococcal infection that triggers the autoimmune response, with prospective studies showing that OCD symptoms promptly disappeared when children were treated with antibiotics effective against Group A Streptococcus at the sentinel episode 3.
Treatment Duration and Monitoring
A minimum 10-day course is essential to prevent acute rheumatic fever and ensure complete eradication of Streptococcus pyogenes 4, 5. Post-treatment throat cultures are indicated only in patients who remain symptomatic, experience symptom recurrence, or have a history of rheumatic fever 1.
For treatment failures, consider alternative antibiotics such as clindamycin, narrow-spectrum cephalosporins, amoxicillin-clavulanic acid, or combination therapy with penicillin plus rifampin 1.
Chronic Prophylaxis Considerations
Chronic secondary antimicrobial prophylaxis is suggested for children with PANDAS who have:
- Severe neuropsychiatric symptoms, OR
- Recurrent Group A Streptococcus-associated exacerbations 6
However, it is critical to note that the American Heart Association does not recommend long-term antistreptococcal prophylaxis as routine practice 1, 7, 2.
Adjunctive Psychiatric Management
While antibiotics address the infectious trigger, psychotherapy has demonstrated significant efficacy in managing obsessive-compulsive symptoms, particularly in reducing stress for both patients and parents 8. Antipsychotic medications may be considered for severe neuropsychiatric symptoms (used in 24.2% of cases in one retrospective study) 8.
Important Caveats and Limitations
PANDAS remains a controversial diagnosis. The American Heart Association explicitly states that PANDAS "should be considered only as a yet-unproven hypothesis" 1, 7, 2. Despite this controversy, the American Heart Association does NOT recommend:
- Routine laboratory testing for Group A Streptococcus solely to diagnose PANDAS 7, 2
- Immunoregulatory therapy (IVIG, plasma exchange) as first-line treatment 1, 7, 2
- Long-term antistreptococcal prophylaxis as routine practice 1, 7, 2
Common pitfall: Treating based solely on elevated streptococcal antibody titers without documented acute infection. Anti-streptolysin O (ASO) peaks 3-6 weeks after infection and anti-DNase B peaks 6-8 weeks post-infection, so elevated titers may reflect past rather than current infection 7.
Ongoing Surveillance
All patients with PANDAS should be closely monitored for intercurrent infections, including streptococcal pharyngitis or dermatitis in the patient and close contacts, as well as sinusitis and influenza 6. Any intercurrent infections should be diagnosed and treated promptly according to current standard guidelines 6.