Initial Treatment for PANDAS

Diagnostic Considerations

The American Heart Association notes that PANDAS should be considered only as a "yet-unproven hypothesis" 1, 2
PANDAS is characterized by sudden-onset obsessive-compulsive symptoms and/or tics precipitated by streptococcal infection 1, 3

The initial treatment for a patient presenting with PANDAS infections should be antibiotics to eradicate the streptococcal infection, specifically penicillin or amoxicillin for 10 days 1
Preferred antibiotic options include oral penicillin V (500 mg four times a day for 10 days) 4
Amoxicillin (500 mg three times a day for 10 days) is also a preferred option 4
For penicillin-allergic patients, erythromycin is a suitable alternative 5
Clindamycin (300 mg four times a day for 10 days) may be used, especially for eradication failures 4
Azithromycin (maximum dose of 500 mg once a day for 3-5 days) is another option for penicillin-allergic patients 4
Intramuscular benzathine penicillin G for patients unlikely to complete oral therapy 5

Post-treatment throat cultures are indicated only in patients who remain symptomatic, experience symptom recurrence, or have a history of rheumatic fever 6
For treatment failures, consider alternative antibiotics such as clindamycin, narrow-spectrum cephalosporins, or amoxicillin-clavulanic acid 6
Consider combination therapy with penicillin plus rifampin for treatment failures 6

The American Heart Association does not recommend routine laboratory testing for GAS to diagnose PANDAS 2
The American Heart Association does not recommend long-term antistreptococcal prophylaxis to prevent PANDAS 1
The American Heart Association does not recommend immunoregulatory therapy (e.g., IVIG, plasma exchange) as first-line treatment 1, 2
Plasma exchange has been proposed but lacks strong evidence 1, 2

Amoxicillin is an equally effective alternative to penicillin for PANDAS, often preferred for young children due to better taste acceptance, as recommended by the Infectious Diseases Society of America 7