Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected viral aetiology

1st line – urgent hospital admission + intravenous aciclovir

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INITIAL
|
suspected viral aetiology
1st line – 

urgent hospital admission + intravenous aciclovir

Treatment with intravenous aciclovir should be started promptly.[2] Suspected tick-borne encephalitis (TBE) is treated like herpes simplex virus (HSV) encephalitis. In patients with HSV, this recommendation is supported by biopsy-proven randomised controlled trials, showing reduced mortality.[34][38]

Patients should be admitted to hospital immediately. Some patients with milder symptoms and signs can be managed in a regular nursing unit, with access to an ICU bed if needed. All other patients, and in particular those with complications (e.g., significant electrolyte abnormalities, strokes, elevated intracranial pressure [ICP], cerebral oedema, coma, seizures activity, or status epilepticus), should be managed in an ICU, preferably a neurointensive care unit.[36][37]

Once HSV/varicella zoster virus infection is ruled out, empirical aciclovir should be stopped.

Primary options

aciclovir: children 3 months to 11 years of age: 500 mg/square metre of body surface area intravenously every 8 hours for 10-21 days; children ≥12 years of age and adults: 10 mg/kg intravenously every 8 hours for 10-21 days

Plus – supportive care

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INITIAL
|
suspected viral aetiology
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

In patients with elevated intracranial pressure (ICP), management with corticosteroids and/or mannitol may be considered.[39] Consensus guidelines do not recommend routine use of corticosteroids or hyperosmolar therapy for treatment of ICP in patients with TBE; however, this is based on poor quality evidence as data for TBE are lacking.[2] In practice, these agents are often used.

Initial measures are: elevation of the head of the bed to between 30° and 45°, avoiding compression of the jugular veins, and hyperventilation to a PaCO2 of around 30. Subsequently, hyperosmolar therapy with mannitol boluses or hypertonic saline can be used to decrease ICP.

Shunting or surgical decompression (by craniectomy) is indicated in some cases where medical management has failed to control elevated ICP, and for impending uncal herniation.[31] This can be considered no matter the aetiology of encephalitis; however, most outcome data have been published for viral encephalitis.

Other supportive care may include endotracheal intubation and mechanical ventilation, circulatory and electrolyte support, prevention and management of secondary bacterial infections, DVT prophylaxis, and gastrointestinal (ulcer) prophylaxis.

Primary options

dexamethasone sodium phosphate: children: consult specialist for guidance on dose; adults: 10 mg intravenously initially, followed by 4 mg every 6 hours until symptoms subside, and then reduce dose gradually

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and/or

mannitol: children: consult specialist for guidance on dose; adults: 0.25 to 2 g/kg intravenously initially, followed by 0.25 to 1 g/kg every 4 hours

ACUTE

confirmed TBE

1st line – supportive care

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ACUTE
|
confirmed TBE
1st line – 

supportive care

In patients with elevated intracranial pressure (ICP), management with corticosteroids and/or mannitol may be considered.[39] Consensus guidelines do not recommend routine use of corticosteroids or hyperosmolar therapy for treatment of patients with ICP due to TBE; however, this is based on poor quality evidence as data for TBE are lacking.[2] In practice, these agents are often used.

Initial measures are: elevation of the head of the bed to between 30° and 45°, avoiding compression of the jugular veins, and hyperventilation to a PaCO2 of around 30. Subsequently, hyperosmolar therapy with mannitol boluses or hypertonic saline can be used to decrease ICP.

Shunting or surgical decompression (by craniectomy) is indicated in some cases where medical management has failed to control elevated ICP, and for impending uncal herniation.[31] This can be considered no matter the aetiology of encephalitis; however, most outcome data have been published for viral encephalitis.

Other supportive care may include endotracheal intubation and mechanical ventilation, circulatory and electrolyte support, prevention and management of secondary bacterial infections, DVT prophylaxis, and gastrointestinal (ulcer) prophylaxis.

Once herpes simplex/varicella zoster virus infection is ruled out, empirical aciclovir should be stopped.

Primary options

dexamethasone sodium phosphate: children: consult specialist for guidance on dose; adults: 10 mg intravenously initially, followed by 4 mg every 6 hours until symptoms subside, and then reduce dose gradually

More

and/or

mannitol: children: consult specialist for guidance on dose; adults: 0.25 to 2 g/kg intravenously initially, followed by 0.25 to 1 g/kg every 4 hours

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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