Sandbox ID Central Nervous System

# Central Nervous System

## Brain abscess   Return to Top 
- 1. Empiric antimicrobial therapy
- 1.1 Brain abscess in otherwise healthy patients
- Preferred regimen (1): (Cefotaxime 812 g/day IV q46h OR Ceftriaxone 4 g/day IV q12h) AND Metronidazole 30 mg/kg/day IV q6h
- Alternative regimen (1): Meropenem 6 g/day IV q8h
- 1.2 Brain abscess with comorbidities
- 1.2.1 Otitis media, mastoiditis, or sinusitis
- Preferred regimen (1): (Cefotaxime 812 g/day q46h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h
- 1.2.2 Dental infection
- Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h
- 1.2.3 Penetrating trauma or post-neurosurgy
- Preferred regimen (1): (Cefotaxime 812 g/day q46h OR Ceftriaxone 4 g/day q12h OR Cefepime 2 g IV q12h) AND Vancomycin 3045 mg/kg/day q812h
- 1.2.4 Lung abscess, empyema, or bronchiectasis
- Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h AND TMP-SMZ 1020 mg/kg/day q612h
- 1.2.5 Bacterial endocarditis
- Preferred regimen: Vancomycin 3045 mg/kg/day q812h AND Gentamicin 5 mg/kg/day IV q8h
- 1.2.6 Congenital heart disease
- Preferred regimen (1): Cefotaxime 812 g/day q46h
- Preferred regimen (2): Ceftriaxone 4 g/day q12h
- 1.2.7 Transplant recipients
- Preferred regimen (1): (Cefotaxime 812 g/day q46h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h AND Voriconazole 8 mg/kg/day q12h AND (TMP-SMZ 1020 mg/kg/day q612h OR Sulfadiazine 46 g/day q6h)
- 1.2.8 Patients with HIV/AIDS
- Preferred regimen (1): (Cefotaxime 812 g/day q46h OR Ceftriaxone 4 g/day q12h) AND Sulfadiazine 46 g/day q6h AND Pyrimethamine 25100 mg/day qd
- 1.2.9  Staphylococcus aureus coverage
- Preferred regimen: Vancomycin 3045 mg/kg/day q812h
- 1.2.10 Mycobacterium tuberculosis coverage
- Preferred regimen: Isoniazid 300 mg qd AND Rifampin 600 mg qd AND Pyrazinamide 1530 mg qd AND Ethambutol 15 mg/kg/day qd
- 2. Pathogen-directed antimicrobial therapy
- 2.1 Bacteria
- 2.1.1 Actinomyces
- Preferred regimen: Penicillin G 4 MU IV q4h
- Alternative regimen: Clindamycin 24004800 mg/day IV q6h
- 2.1.2 Bacteroides fragilis
- Preferred regimen: Metronidazole 30 mg/kg/day IV q6h
- Alternative regimen: Clindamycin 24004800 mg/day IV q6h
- 2.1.3 Enterobacteriaceae
- Preferred regimen (1): Cefotaxime 2 g IV q4-6h
- Preferred regimen (2): Ceftriaxone 2 g IV q12h
- Preferred regimen (3): Cefepime 2 g IV q12h
- Alternative regimen (1): Aztreonam 68 g/day IV q68h
- Alternative regimen (2): TMP-SMZ 1020 mg/kg/day q612h
- Alternative regimen (3): Ciprofloxacin 8001200 mg/day IV q812h
- Alternative regimen (4): Meropenem 2 g IV q8h
- 2.1.4 Fusobacterium
- Preferred regimen: Metronidazole 30 mg/kg/day q6h
- Alternative regimen (1): Clindamycin 24004800 mg/day IV q6h
- Alternative regimen (2): Meropenem 2 g IV q8h
- 2.1.5 Haemophilus
- Preferred regimen (1): Cefotaxime 2 g IV q4-6h
- Preferred regimen (2): Ceftriaxone 2 g IV q12h
- Preferred regimen (3): Cefepime 2 g IV q12h
- Alternative regimen (1): Aztreonam 68 g/day IV q68h
- Alternative regimen (2): TMP-SMZ 1020 mg/kg/day q612h
- 2.1.6 Listeria monocytogenes
- Preferred regimen (1): Ampicillin 12 g/day q4h
- Preferred regimen (2): Penicillin G 4 MU IV q4h
- Alternative regimen (1): TMP-SMZ 1020 mg/kg/day q612h
- 2.1.7 Nocardia
- Preferred regimen (1): TMP-SMZ 1020 mg/kg/day q612h
- Preferred regimen (2): Sulfadiazine 46 g/day q6h
- Alternative regimen (1): Meropenem 2 g IV q8h
- Alternative regimen (2): Cefotaxime 2 g IV q4-6h
- Alternative regimen (3): Ceftriaxone 2 g IV q12h
- Alternative regimen (4): Amikacin 15 mg/kg/day IV q8h
- 2.1.8 Prevotella melaninogenica
- Preferred regimen (1): Metronidazole 30 mg/kg/day q6h
- Alternative regimen (1): Clindamycin 24004800 mg/day IV q6h
- Alternative regimen (2): Meropenem 2 g IV q8h
- 2.1.9 Pseudomonas aeruginosa
- Preferred regimen (1): Ceftazidime 6 g/day q8h
- Preferred regimen (2): Cefepime 6 g/day q8h
- Alternative regimen (1): Aztreonam 68 g/day IV q68h
- Alternative regimen (2): Ciprofloxacin 8001200 mg/day IV q812h
- Alternative regimen (3): Meropenem 2 g IV q8h
- 2.1.10 Staphylococcus aureus, methicillin-resistant (MRSA)
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h for 46 weeks
- Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 46 weeks
- Alternative regimen (2):TMP-SMX 5 mg/kg/dose PO/IV q812h for 46 weeks
- Pediatric dose (1): Vancomycin 15 mg/kg/dose IV q6h
- Pediatric dose (2): Linezolid 10 mg/kg/dose PO/IV q8h
- Note: Consider the addition of Rifampin 600 mg qd or 300450 mg bid to vancomycin.
- 2.1.11 Staphylococcus aureus, methicillin-susceptible (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q4h
- Preferred regimen (2): Oxacillin 2 g IV q4h
- Alternative regimen: Vancomycin 3045 mg/kg/day IV q812h
- 2.1.12 Streptococcus
- Preferred regimen (1): Penicillin G 4 MU IV q4h
- Preferred regimen (2): Ampicillin 2 g IV q4h
- Alternative regimen (1): Cefotaxime 2 g IV q4-6h
- Alternative regimen (2): Ceftriaxone 2 g IV q12h
- Alternative regimen (3): Vancomycin 3045 mg/kg/day IV q812h
- 2.2 Fungi
- 2.2.1 Aspergillus
- Preferred regimen: Voriconazole 8 mg/kg/day q12h
- Alternative regimen (1): Amphotericin B deoxycholate 0.61.0 mg/kg/day IV q24h
- Alternative regimen (2): Amphotericin B lipid complex 5 mg/kg/day IV q24h
- Alternative regimen (3): Itraconazole 400600 mg/day IV q12h
- Alternative regimen (4): Posaconazole 800 mg/kg/day IV q612h
- 2.2.2 Candida
- Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
- Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
- Alternative regimen: Fluconazole 400800 mg/day IV q24h
- 2.2.3 Cryptococcus neoformans
- Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
- Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
- Alternative regimen: Fluconazole 400800 mg/day IV q24h
- 2.2.4 Mucorales
- Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
- Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
- Alternative regimen: Posaconazole 800 mg/kg/day IV q612h
- 2.2.5 Pseudallescheria boydii (Scedosporium apiospermum)
- Preferred regimen: Voriconazole 8 mg/kg/day q12h
- Alternative regimen (1): Itraconazole 400600 mg/day IV q12h
- Alternative regimen (2):Posaconazole 800 mg/kg/day IV q612h
- 2.3 Protozoa
- 2.3.1 Toxoplasma gondii
- Preferred regimen: Sulfadiazine 46 g/day q6h AND Pyrimethamine 25100 mg/day qd
- Alternative regimen (1): Pyrimethamine 25100 mg/day qd AND Clindamycin 24004800 mg/day IV q6h
- Alternative regimen (2): Pyrimethamine 25100 mg/day qd AND (Azithromycin 12001500 mg/day IV q24h
- Alternative regimen (3): Atovaquone 750 mg IV q6h
- Alternative regimen (4): Dapsone 100 mg PO q24h
- Alternative regimen (4): TMP-SMZ 1020 mg/kg/day q612h

## Cerebrospinal fluid shunt infection   Return to Top 
- 1. Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h AND (Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h OR Meropenem 2 g IV q8h)
- 2. Pathogen-directed antimicrobial therapy
- 2.1 Enterococcus
- Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) AND Gentamicin 11.7 mg/kg IV q8h
- 2.2 Gram-negative bacilli
- Preferred regimen: Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h OR Meropenem 2 g IV q8h OR Aztreonam 2 g IV q6h
- 2.3 Propionibacterium acnes
- Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h)  Gentamicin 11.7 mg/kg IV q8h
- 2.4 Staphylococcus, coagulase-negative
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h  Rifampin 600 mg IV/PO q24h
- 2.5 Staphylococcus aureus, methicillin-resistant (MRSA)
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h  Rifampin 600 mg IV/PO q24h
- 2.6 Staphylococcus aureus, methicillin-susceptible (MSSA)
- Preferred regimen: (Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h)  Rifampin 600 mg IV/PO q24h
- 2.7 Streptococcus agalactiae
- Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) AND Gentamicin 11.7 mg/kg IV q8h
- 2.8 Fungi
- Preferred regimen: Amphotericin B 0.61.0 mg/kg IV q24h OR Amphotericin B liposomal 5 mg/kg/day IV q24h

## Encephalitis   Return to Top 
- 1. Empiric antimicrobial therapy
- Preferred regimen: Acyclovir 10 mg/kg IV q8h for 1421 days
- Note (1): Acyclovir should be initiated in all patients with suspected encephalitis, pending results of diagnostic studies.
- Note (2): Other empiric antimicrobial agents should be administered on the basis of specific epidemiologic or clinical clues.
- 2. Specific epidemiologic considerations
- 2.1 Agammaglobulinemia  Enteroviruses, Mycoplasma pneumoniae
- 2.2 Age
- 2.2.1 Neonates  Herpes simplex virus type 2, cytomegalovirus, rubella virus, Listeria monocytogenes, Treponema pallidum, Toxoplasma gondii
- 2.2.2 Infants and children  Eastern equine encephalitis virus, Japanese encephalitis virus, Murray Valley encephalitis virus, influenza virus, La Crosse virus
- 2.2.3 Elderly persons  Eastern equine encephalitis virus, St. Louis encephalitis virus, West Nile virus, sporadic CJD, L. monocytogenes
- 2.3 Animal contact
- 2.3.1 Bats  Rabies virus, Nipah virus
- 2.3.2 Birds  West Nile virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, Cryptococcus neoformans (bird droppings)
- 2.3.3 Cats  Rabies virus, Coxiella burnetii, Bartonella henselae, T. gondii
- 2.3.4 Dogs  Rabies virus
- 2.3.5 Horses  Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, Hendra virus
- 2.3.6 Old World primates  B virus
- 2.3.7 Raccoons  Rabies virus, Baylisascaris procyonis
- 2.3.8 Rodents  Eastern equine encephalitis virus (South America), Venezuelan equine encephalitis virus, tickborne encephalitis virus, Powassan virus (woodchucks), La Crosse virus (chipmunks and squirrels), Bartonella quintana
- 2.3.9 Sheep and goats  C. burnetii
- 2.3.10 Skunks  Rabies virus
- 2.3.11 Swine  Japanese encephalitis virus, Nipah virus
- 2.3.12 White-tailed deer  Borrelia burgdorferi
- 2.4 Immunocompromised persons  Varicella zoster virus, cytomegalovirus, human herpesvirus 6, West Nile virus, HIV, JC virus, L. monocytogenes, Mycobacterium tuberculosis, C. neoformans, Coccidioides species, Histoplasma capsulatum, T. gondii
- 2.5 Ingestion
- 2.5.1 Raw or partially cooked meat  T. gondii
- 2.5.2 Raw meat, fish, or reptiles  Gnanthostoma species
- 2.5.3 Unpasteurized milk  Tickborne encephalitis virus, L. monocytogenes, C. burnetii
- 2.6 Insect contact
- 2.6.1 Mosquitoes  Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, West Nile virus, La Crosse virus, Plasmodium falciparum
- 2.6.2 Sandflies  Bartonella bacilliformis
- 2.6.3 Ticks  Tickborne encephalitis virus, Powassan virus, Rickettsia rickettsii, Ehrlichia chaffeensis, Anaplasma phagocytophilum, C. burnetii (rare), B. burgdorferi
- 2.6.4 Tsetse flies  Trypanosoma brucei gambiense, Trypanosoma brucei rhodesiense
- 2.7 Occupation
- 2.7.1 Exposure to animals  Rabies virus, C. burnetii, Bartonella species
- 2.7.2 Exposure to horses  Hendra virus
- 2.7.3 Exposure to Old World primates  B virus
- 2.7.4 Laboratory workers  West Nile virus, HIV, C. burnetii, Coccidioides species
- 2.7.5 Physicians and health care workers  Varicella zoster virus, HIV, influenza virus, measles virus, M. tuberculosis
- 2.7.6 Veterinarians  Rabies virus, Bartonella species, C. burnetii
- 2.8 Person-to-person transmission  Herpes simplex virus (neonatal), varicella zoster virus, Venezuelan equine encephalitis virus (rare), poliovirus, nonpolio enteroviruses, measles virus, Nipah virus, mumps virus, rubella virus, Epstein-Barr virus, human herpesvirus 6, B virus, West Nile virus (transfusion, transplantation, breast feeding), HIV, rabies virus (transplantation), influenza virus, M. pneumoniae, M. tuberculosis, T. pallidum
- 2.9 Recent vaccination  Acute disseminated encephalomyelitis
- 2.10 Recreational activities
- 2.10.1 Camping/hunting  Agents transmitted by mosquitoes and ticks
- 2.10.2 Sexual contact  HIV, T. pallidum
- 2.10.3 Spelunking  Rabies virus, H. capsulatum
- 2.10.4 Swimming  Enteroviruses, Naegleria fowleri
- 2.11 Season
- 2.11.1 Late summer/early fall  Agents transmitted by mosquitoes and ticks, enteroviruses
- 2.11.2 Winter  Influenza virus
- 2.12 Transfusion and transplantation  Cytomegalovirus, Epstein-Barr virus, West Nile virus, HIV, tickborne encephalitis virus, rabies virus, iatrogenic CJD, T. pallidum, A. phagocytophilum, R. rickettsii, C. neoformans, Coccidioides species, H. capsulatum, T. gondii
- 2.13 Travel
- 2.13.1 Africa  Rabies virus, West Nile virus, P. falciparum, T. brucei gambiense, T. brucei rhodesiense
- 2.13.2 Australia  Murray Valley encephalitis virus, Japanese encephalitis virus, Hendra virus
- 2.13.3 Central America  Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, P. falciparum, Taenia solium
- 2.13.4 Europe  West Nile virus, tickborne encephalitis virus, A. phagocytophilum, B. burgdorferi
- 2.13.5 India, Nepal  Rabies virus, Japanese encephalitis virus, P. falciparum
- 2.13.6 Middle East  West Nile virus, P. falciparum
- 2.13.7 Russia  Tickborne encephalitis virus
- 2.13.8 South America  Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, B. bacilliformis (Andes mountains), P. falciparum, T. solium
- 2.13.9 Southeast Asia, China, Pacific Rim  Japanese encephalitis virus, tickborne encephalitis virus, Nipah virus, P. falciparum, Gnanthostoma species, T. solium
- 2.13.10 Unvaccinated status  Varicella zoster virus, Japanese encephalitis virus, poliovirus, measles virus, mumps virus, rubella virus
- 3. Specific clinical considerations
- 3.1 General findings
- 3.1.1 Hepatitis  Coxiella burnetii
- 3.1.2 Lymphadenopathy  HIV, Epstein-Barr virus, cytomegalovirus, measles virus, rubella virus, West Nile virus, Treponema pallidum, Bartonella henselae and other Bartonella species, Mycobacterium tuberculosis, Toxoplasma gondii, Trypanosoma brucei gambiense
- 3.1.3 Parotitis  Mumps virus
- 3.1.4 Rash  Varicella zoster virus, B virus, human herpesvirus 6, West Nile virus, rubella virus, some enteroviruses, HIV, Rickettsia rickettsii, Mycoplasma pneumoniae, Borrelia burgdorferi, T. pallidum, Ehrlichia chaffeensis, Anaplasma phagocytophilum
- 3.1.5 Respiratory tract findings  Venezuelan equine encephalitis virus, Nipah virus, Hendra virus, influenza virus, adenovirus, M. pneumoniae, C. burnetii, M. tuberculosis, Histoplasma capsulatum
- 3.1.6 Retinitis  Cytomegalovirus, West Nile virus, B. henselae, T. pallidum
- 3.1.7 Urinary symptoms  St. Louis encephalitis virus
- 3.2 Neurologic findings
- 3.2.1 Cerebellar ataxia  Varicella zoster virus (children), Epstein-Barr virus, mumps virus, St. Louis encephalitis virus, Tropheryma whipplei, T. brucei gambiense
- 3.2.2 Cranial nerve abnormalities  Herpes simplex virus, Epstein-Barr virus, Listeria monocytogenes, M. tuberculosis, T. pallidum, B. burgdorferi, T. whipplei, Cryptococcus neoformans, Coccidioides species, H. capsulatum
- 3.2.3 Dementia  HIV, human transmissible spongiform encephalopathies (sCJD and vCJD), measles virus (SSPE), T. pallidum, T. whipplei
- 3.2.4 Myorhythmia  T. whipplei (oculomasticatory)
- 3.2.5 Parkinsonism  Japanese encephalitis virus, St. Louis encephalitis virus, West Nile virus, Nipah virus, T. gondii, T. brucei gambiense
- 3.2.6 Poliomyelitis-like flaccid paralysis  Japanese encephalitis virus, West Nile virus, tickborne encephalitis virus; enteroviruses (enterovirus-71, coxsackieviruses), poliovirus
- 3.2.7 Rhombencephalitis  Herpes simplex virus, West Nile virus, enterovirus 71, L. monocytogenes
- 4. Pathogen-directed antimicrobial therapy
- 4.1 Viruses
- 4.1.1 Adenovirus
- Preferred regimen: supportive
- 4.1.2 B virus (herpes B virus)
- 4.1.2.1 Established disease
- Preferred regimen: Valacyclovir 1,000 mg PO tid OR Ganciclovir 5 mg/kg IV q12h for  14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily indefinitely OR Valacyclovir 1 g PO tid indefinitely
- Alternative regimen: Acyclovir 15 mg/kg IV q8h for  14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily OR Valacyclovir 1 g PO tid indefinitely
- 4.1.2.2 Prophylaxis after bite or scratch
- Preferred regimen: Valacyclovir 1,000 mg PO tid
- 4.1.3 Cytomegalovirus (CMV)
- Preferred regimen: Ganciclovir 5 mg/kg IV q12h for 1421 days, followed by 5 mg/kg IV qd for maintenance AND Foscarnet 90 mg/kg IV q12h for 1421 days, followed by 90-120 mg/kg IV qd for maintenance
- 4.1.4 Chikungunya virus
- Preferred regimen: supportive
- 4.1.5 Eastern equine encephalitis virus
- Preferred regimen: supportive
- 4.1.6 Epstein-Barr virus (EBV)
- Preferred regimen: supportive  Corticosteroids
- Note: Acyclovir is not recommended.
- 4.1.7 Hendra virus
- Preferred regimen: supportive
- 4.1.8 HSV-1 and HSV-2
- Preferred regimen: Acyclovir 10 mg/kg IV q8h for 1421 days
- Preferred regimen (neonates): Acyclovir 20 mg/kg IV q8h for 21 days
- 4.1.9 Human herpesvirus 6 (HHV-6)
- Preferred regimen (1): Ganciclovir 5 mg/kg IV q12h for 1421 days, followed by 5 mg/kg IV qd for maintenance
- Preferred regimen (2): Foscarnet 90 mg/kg IV q12h for 1421 days, followed by 90-120 mg/kg IV qd for maintenance
- 4.1.10 Human immunodeficiency virus (HIV)
- Preferred regimen: HAART
- 4.1.11 Influenza virus
- Preferred regimen: Oseltamivir 75 mg PO bid
- 4.1.12 Japanese encephalitis virus
- Preferred regimen: supportive
- Note: Interferon alpha is not recommended.
- 4.1.13 JC virus
- Preferred regimen: Reversal or control of immunosuppression OR HAART in patients with AIDS
- 4.1.14 La Crosse virus
- Preferred regimen: supportive
- 4.1.15 Louping ill virus
- Preferred regimen: supportive
- 4.1.16 Lymphocytic choriomeningitis virus (LCMV)
- Preferred regimen: supportive
- 4.1.17 Me Tri virus
- Preferred regimen: supportive
- 4.1.18 Measles virus
- Preferred regimen: supportive
- Note: Ribavirin is not approved by the US Food and Drug Administration (FDA) for this indication, and such use should be considered experimental.
- 4.1.19 Monkeypox virus
- Preferred regimen: supportive
- Alternative regimen: Cidofovir OR vaccinia immune globulin
- 4.1.20 Mumps virus
- Preferred regimen: supportive
- 4.1.21 Murray Valley encephalitis virus
- Preferred regimen: supportive
- 4.1.22 Nipah virus
- Preferred regimen: supportive
- Alternative regimen: Ribavirin
- 4.1.23 Nonpolio enteroviruses
- Preferred regimen: supportive
- Note: Consider intraventricular -globulin for chronic and/or severe disease.
- 4.1.24 Poliovirus
- Preferred regimen: supportive
- 4.1.25 Powassan virus
- Preferred regimen: supportive
- 4.1.26 Rabies virus
- 4.1.26.1 Not previously vaccinated
- Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
- Preferred regimen (2): Human rabies immune globulin (HRIG) 20 IU/kg
- Preferred regimen (3): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14
- 4.1.26.2 Previously vaccinated
- Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
- Preferred regimen (2): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0 and 3
- Note:  If anatomically feasible, the full dose of HRIG should be infiltrated around and into the wounds, and any remaining volume should be administered at an anatomical site intramuscularly distant from vaccine administration.  In addition, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered.
- 4.1.27 Rocio virus
- Preferred regimen: supportive
- 4.1.28 Rubella virus
- Preferred regimen: supportive
- 4.1.29 Snowshoe hare virus
- Preferred regimen: supportive
- 4.1.30 St. Louis encephalitis virus
- Preferred regimen: supportive
- Alternative regimen: IFN--2b
- 4.1.31 Tickborne encephalitis virus
- Preferred regimen: supportive
- 4.1.32 Toscana virus
- Preferred regimen: supportive
- 4.1.33 Vaccinia
- Preferred regimen: supportive  Corticosteroids (if suggestive of post-immunization)
- 4.1.34 Venezuelan equine encephalitis virus
- Preferred regimen: supportive
- 4.1.35 Varicella zoster virus (VZV)
- Preferred regimen: Acyclovir 1015 mg/kg IV q8h for 1014 days  Corticosteroids
- Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 1421 days THEN 5 mg/kg IV qd for maintenance  Corticosteroids
- 4.1.36 West Nile virus
- Preferred regimen: supportive
- 4.1.37 Western equine encephalitis virus
- Preferred regimen: supportive
- 4.2 Bacteria
- 4.2.1 Anaplasma phagocytophilum (human granulocytotrophic ehrlichiosis)
- Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks
- 4.2.2 Bartonella bacilliformis (Oroya fever, Carrion's disease)
- Preferred regimen: Chloramphenicol 25 mg/kg q6h for 14 days OR Doxycycline 100 mg PO/IV bid for 8 weeks OR Ampicillin 2 mg IV q4h for 3-6 weeks OR Trimethoprim-Sulfamethoxazole 4 mg/kg IV q6h for 3-6 weeks
- 4.2.3 Bartonella henselae (cat scratch disease)
- Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks OR Azithromycin 250 mg PO qd for 8 weeks  Rifampin 300 mg PO bid for 8 weeks
- 4.2.4 Borrelia burgdorferi (Lyme disease)
- Preferred regimen: Ceftriaxone 2g IV q24h for 2-4 weeks OR Cefotaxime 2g IV q8h for 2-4 weeks OR Penicillin G 20MU IV q4hr in divided doses for 2-4 weeks
- 4.2.5 Coxiella burnetii (Q fever)
- Preferred regimen:  Doxycycline 100 mg IV/PO bid for 8 weeks AND Ciprofloxacin 500-750 mg PO bid for 8 weeks AND Rifampin 300 mg PO bid for 8 weeks
- 4.2.6 Ehrlichia chaffeensis (human monocytotrophic ehrlichiosis)
- Preferred regimen: Doxycycline 100 mg IV/PO bid for 8 weeks
- 4.2.7 Listeria monocytogenes
- Preferred regimen: Ampicillin 2 mg IV q4h for 3-6 weeks AND Gentamicin 5 mg/kg/day IV divided q8h for 3-6 weeks
- Alternative regimen: Trimethoprim-Sulfamethoxazole 4 mg/kg IV q6h for 3-6 weeks
- 4.2.8 Mycobacterium tuberculosis
- Preferred regimen: (Isoniazid 300 mg PO qd for 10-12 months AND Rifampicin 450-600 mg PO qd for 10-12 months AND Pyrazinamide 1.5-2g mg PO qd for 2 months AND Ethambutol 15 mg/kg PO qd for 2 month)  Dexamethasone (if suggestive of meningitis)
- 4.2.9 Mycoplasma pneumoniae
- Preferred regimen: Azithromycin 250 mg PO qd for 8 weeks OR Doxycycline 100 mg PO/IV bid for 8 weeks
- 4.2.10 Rickettsia rickettsii (Rocky Mountain spotted fever)
- Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks
- Alternative regimen, pregnant patient: Chloramphenicol 25 mg/kg q6h for 14 days
- 4.2.11 Treponema pallidum (syphilis)
- Preferred regimen: Penicillin G 20MU IV q4hr in divided doses for 2-4 weeks
- Alternative regimen: Ceftriaxone 2g IV q24h for 2-4 weeks
- 4.2.12 Tropheryma whipplei (Whipple's disease)
- Preferred regimen: Ceftriaxone 2g IV q24h for 2-4 weeks, followed by Trimethoprim-Sulfamethoxazole for 12 years OR Cefixime for 12 years
- 4.3 Fungi
- 4.3.1 Coccidioides
- Preferred regimen: Fluconazole 400-800 mg IV qd for 3-4 weeks
- Alternative regimen: Itraconazole 200 mg IV bid for 2 days THEN 200 mg IV qd for 12 days OR Voriconazole OR Amphotericin B (intravenous and intrathecal)
- 4.3.2 Cryptococcus neoformans
- Preferred regimen (1): Amphotericin B deoxycholate AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
- Preferred regimen (2): Amphotericin B lipid complex AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
- Preferred regimen (3): Amphotericin B deoxycholate AND Flucytosine for 610 weeks, followed by Fluconazole for 8 weeks
- Note: Consider placement of lumbar drain or VP shunt.
- 4.3.3 Histoplasma capsulatum
- Preferred regimen: Amphotericin B liposomal for 46 weeks, followed by Itraconazole for at least 1 year and until resolution of CSF abnormalities
- 4.4 Protozoa
- 4.4.1 Acanthamoeba
- Preferred regimen (1): Trimethoprim-Sulfamethoxazole AND Rifampin AND Ketoconazole
- Preferred regimen (2): Fluconazole AND Sulfadiazine AND Pyrimethamine 100-200 mg PO once THEN 50-100 mg PO qd for 6 weeks
- 4.4.2 Balamuthia mandrillaris
- Preferred regimen: (Azithromycin OR Clarithromycin) AND Pentamidine AND Flucytosine AND Fluconazole AND Sulfadiazine AND (Thioridazine OR Trifluoperazine)
- 4.4.3 Naegleria fowleri
- Preferred regimen: Amphotericin B (intravenous and intrathecal) AND Rifampin AND (Azithromycin OR Sulfisoxazole OR Miconazole)
- 4.4.4 Plasmodium falciparum
- Preferred regimen: Quinine OR Quinidine OR Artesunate OR Artemether
- Alternative regimen (1): Atovaquone-Proguanil
- Alternative regimen (2): Exchange transfusion (for > 10% parasitemia or cerebral malaria)
- 4.4.5 Toxoplasma gondii
- Preferred regimen: Pyrimethamine AND Sulfadiazine OR Clindamycin 900 mg IV q 6hr qd for 6 weeks
- Alternative regimen (1): Trimethoprim-sulfamethoxazole
- Alternative regimen (2): Pyrimethamine AND (Atovaquone OR Clarithromycin OR Azithromycin OR Dapsone)
- 4.4.6 Trypanosoma brucei gambiense (West African trypanosomiasis)
- Preferred regimen: Eflornithine OR Melarsoprol 2-3.6 mg/kg IV q24h for 3 days THEN repeat the same regimen after 7 days THEN repeat the same regimen again (total of 3 regimens after 7 days of the 2nd regimen
- 4.4.7 Trypanosoma brucei rhodesiense (East African trypanosomiasis)
- Preferred regimen: Melarsoprol
- 4.5 Helminths
- 4.5.1 Baylisascaris procyonis
- Preferred regimen: Albendazole AND Diethylcarbamazine AND Corticosteroids
- 4.5.2 Gnathostoma
- Preferred regimen: Albendazole OR Ivermectin
- 4.5.3 Taenia solium (cysticercosis)
- Preferred regimen: Albendazole AND Corticosteroids
- Alternative regimen: Praziquantel AND Corticosteroids
- 4.6 Prion
- 4.6.1 Human transmissible spongiform encephalopathy
- Preferred regimen: supportive