What is the treatment for a child diagnosed with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal (PANDAS) infections after strep throat?

PANDAS After Strep Throat: Treatment Approach

PANDAS remains an unproven hypothesis, and current guidelines explicitly recommend against routine antibiotic prophylaxis, immunomodulatory therapy, or routine streptococcal testing for this condition. 1

Critical Context: PANDAS is Not an Established Diagnosis

The American Heart Association states that PANDAS should be considered only as a yet-unproven hypothesis, and carefully designed studies have not established a causal relationship between streptococcal infections and these neuropsychiatric symptoms 1. The concept was proposed in 1998 suggesting that childhood obsessive-compulsive disorder and/or tics may arise from post-streptococcal autoimmune processes similar to Sydenham chorea 1.

What Guidelines Explicitly Recommend AGAINST

The American Heart Association does not recommend the following for PANDAS (Class III, Level of Evidence B): 1

• Routine laboratory testing for Group A Streptococcus to diagnose PANDAS
• Long-term antistreptococcal prophylaxis to prevent exacerbations
• Immunoregulatory therapy (intravenous immunoglobulin or plasma exchange) to treat exacerbations

These recommendations stand until well-controlled studies establish causation 1.

If Acute Strep Throat is Actually Present

If the child has concurrent acute streptococcal pharyngitis (not PANDAS-related treatment, but treatment of the actual strep infection), treat according to standard guidelines 1:

First-Line Treatment (Non-Allergic Patients)

• Penicillin V: Children 250 mg twice or three times daily for 10 days 1
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days 1
• Benzathine penicillin G IM: <27 kg: 600,000 units; ≥27 kg: 1,200,000 units as single dose 1

Penicillin-Allergic Patients

For non-immediate allergy (delayed rash): 1, 2

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg/dose) for 10 days
• Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days

For immediate/anaphylactic allergy (avoid all beta-lactams): 1, 2

• Clindamycin (preferred): 7 mg/kg per dose three times daily (maximum 300 mg/dose) for 10 days
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg/dose) for 10 days

What Some Research Studies Have Reported (Not Guideline-Endorsed)

While guidelines do not support these approaches, some case series and small studies have reported 3, 4, 5, 6:

• Penicillin during acute phase and for prophylaxis in selected cases
• Prompt antibiotic treatment of documented streptococcal infections when they occur
• Immunomodulatory therapies (plasma exchange, IVIG) in severe cases
• Tonsillectomy in isolated case reports

However, these remain investigational and are not recommended by major guideline organizations 1.

Practical Clinical Approach

If a child presents with new-onset OCD or tics after strep throat: 1

1. Treat any documented acute streptococcal pharyngitis with standard 10-day antibiotic regimens as outlined above 1

2. Refer to pediatric neurology and/or psychiatry for evaluation and management of the neuropsychiatric symptoms with standard therapies for OCD/tic disorders 1

3. Do NOT initiate long-term antibiotic prophylaxis based solely on suspected PANDAS diagnosis 1

4. Do NOT pursue immunomodulatory therapy (IVIG, plasma exchange) outside of research protocols 1

5. Monitor for future streptococcal infections and treat them promptly when documented, but this is standard care for any child, not PANDAS-specific prophylaxis 4

Critical Pitfalls to Avoid

• Do not prescribe long-term prophylactic antibiotics for presumed PANDAS without documented recurrent streptococcal infections, as this lacks evidence and promotes resistance 1

• Do not order extensive streptococcal testing (serial ASO titers, anti-DNase B) to diagnose or manage PANDAS, as this is not recommended 1

• Do not delay appropriate psychiatric/neurologic care while pursuing unproven infection-based treatments 1

• Aspirin must be avoided in children due to Reye syndrome risk 1