Template:ID-Subdural empyema

• Subdural empyema

• Empiric antimicrobial therapy

• Metronidazole is recommended if anaerobes are suspected. Metronidazole is not necessary for antianaerobic activity if Meropenem is used.
• For coverage of aerobic Gram-negative bacilli, empiric therapy with Cefepime, Ceftazidime, or Meropenem is appropriate.
• Depending on the clinical response, parenteral antimicrobial therapy should be administered for 3 to 4 weeks after drainage. Parenteral or oral therapy is frequently continued for up to a total of 6 weeks of therapy.
• A longer course of treatment (minimum of 6–8 weeks) may be required if the patient has accompanying osteomyelitis.
• Consider adjunctive medications including prophylactic anticonvulsants, corticosteroids, and mannitol if clinically indicated.

• Intracranial subdural empyema with unclear source of infection

• Preferred regimen: (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema associated with sinusitis or otitis media

• Preferred regimen: (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema after cranial trauma

• Preferred regimen: Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks
• Note: Vancomycin should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema after neurosurgical procedures

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 3-4 weeks AND Ceftazidime 2 g IV q8h for 3-4 weeks

• Intracranial subdural empyema in neonates (usually associated with meningitis)

• Infants < 1 month

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h for 3-4 weeks AND Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeks

• Infants 1–3 months

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h for 3-4 weeks AND (Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeks OR Ceftriaxone 100 mg/kg/day IV q12h for 3-4 weeks)

• Infants > 3 months

• Preferred regimen: Vancomycin 60 mg/kg/day IV q6h for 3-4 weeks AND (Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeksOR Ceftriaxone 100 mg/kg/day IV q12h for 3-4 weeks OR Cefepime 150 mg/kg/day IV q8h for 3-4 weeks)

• Spinal subdural empyema

• Preferred regimen: Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Pathogen-directed antimicrobial therapy

• Staphylococcus aureus, methicillin-resistant (MRSA)

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
• Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
• Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h OR Linezolid 10 mg/kg/dose PO/IV q8h
• Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin therapy.