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

ACUTE

symptomatic patients

1st line – supportive care

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ACUTE
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symptomatic patients
1st line – 

supportive care

EEEV infection is a notifiable condition in the US and some other countries; therefore, all cases of EEEV infection should be reported to the local health authority in these countries.

There is no specific antiviral treatment for EEEV infection.

Patients may be asymptomatic, or may have symptoms that resemble influenza or dengue fever (e.g., acute onset fever, malaise, headache, chills, nausea, arthralgias, myalgias) with or without neurological (encephalitic) symptoms.

Asymptomatic patients do not require treatment. Patients with febrile illness require supportive care, which includes ample oral fluid intake (i.e., enough fluids to be passing clear urine) and use of analgesics and/or anti-pyretics (e.g., paracetamol).

In the absence of neuroinvasive symptoms, febrile illness usually resolves in 1 to 2 weeks.[5]

Primary options

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Plus – oral or intravenous fluids + anti-emetic

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ACUTE
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symptomatic patients
|
with vomiting and diarrhoea
Plus – 

oral or intravenous fluids + anti-emetic

Treatment recommended for ALL patients in selected patient group

Nausea, vomiting, and diarrhoea may occur in symptomatic patients.

If there is severe dehydration due to vomiting and diarrhoea, the patient is hospitalised, if possible, and oral or intravenous fluids (crystalloids e.g., normal saline or Ringer's lactate solution) are administered along with an anti-emetic agent (e.g., ondansetron).

Initial administration of a single oral dose of ondansetron may obviate the need for intravenous fluids or hospitalisation in children.[42] Other anti-emetics are not recommended due to lack of benefit and risk of adverse effects.

Primary options

ondansetron: children ≥6 months of age and 8-15 kg body weight: 2 mg orally as a single dose; children 15-30 kg body weight: 4 mg orally as a single dose; children >30 kg body weight and adults: 6-8 mg orally as a single dose

Plus – hospitalisation + further supportive care

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ACUTE
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symptomatic patients
|
with neurological symptoms
Plus – 

hospitalisation + further supportive care

Treatment recommended for ALL patients in selected patient group

Neurological/central nervous system involvement is most commonly seen in patients aged over 50 years or under 15 years. However, neurological involvement due to South American EEEV/Madariaga virus (MADV) is more prevalent in children.[16]

Patients exhibiting neurological symptoms (e.g., altered mental status, disorientation, ataxia, seizures, paresis) should be admitted to hospital, if possible.

Airway should be secured by intubation if the patient has altered mental status (e.g., obtundation), and mechanical ventilation initiated.

A cranial nerve examination, fundoscopic examination, and head CT or brain MRI is performed to evaluate for cerebral oedema and elevated intracranial pressure. If intracranial pressure is elevated, head elevation, hyperventilation, and intravenous mannitol may be considered to reduce pressure.[43] In such instances, the placement of an external ventricular device should be considered.

Primary options

mannitol: children: 0.25 to 1 g/kg intravenously initially, followed by 0.25 to 0.5 g/kg every 4 hours; adults: 1-2 g/kg intravenously initially, followed by 0.25 to 1 g/kg every 4 hours

Plus – anticonvulsant

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ACUTE
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symptomatic patients
|
with neurological symptoms
Plus – 

anticonvulsant

Treatment recommended for ALL patients in selected patient group

Patients with neurological involvement are evaluated for seizures, and anticonvulsants administered if there is seizure activity or a history of seizures.

Benzodiazepines are preferred for the initial management of seizures, with lorazepam being most effective due to its long half-life.

Phenytoin is recommended if a second drug is needed to terminate seizures. In pregnant women, phenytoin is only used in life-threatening infection, because it is potentially teratogenic.

Serum drug levels are monitored to ensure that therapeutic levels are achieved.

Primary options

lorazepam: children: 0.05 to 0.1 mg/kg (maximum 4 mg/dose) intravenously as a single dose initially, may repeat once in 10-15 minutes if necessary; adults: 4 mg intravenously as a single dose initially, may repeat once in 10-15 minutes if necessary

Secondary options

phenytoin: children and adults: 15-20 mg/kg intravenously as a loading dose, followed by 5-10 mg/kg as a single dose if necessary; consult specialist for guidance on maintenance dose

Plus – aciclovir

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ACUTE
|
symptomatic patients
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with neurological symptoms
Plus – 

aciclovir

Treatment recommended for ALL patients in selected patient group

Treatment with intravenous aciclovir, to cover for possible herpes simplex virus infection, is recommended in patients with cerebrospinal fluid or imaging findings suggesting viral encephalitis; or if these results will not be available within 6 hours; or if the patient is deteriorating.[39]

Primary options

aciclovir: children: 10-20 mg/kg intravenously every 8 hours; adults: 10 mg/kg intravenously every 8 hours

Plus – empirical antibiotic therapy

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ACUTE
|
symptomatic patients
|
with neurological symptoms
Plus – 

empirical antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Empirical antibiotic therapy should be started until bacterial encephalitis has been ruled out.[38]

Appropriate antibiotics should be guided by local protocols, but should be broad-spectrum.

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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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