Brain abscess medical therapy: Difference between revisions
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{{CMG}} | {{CMG}}; {{AE}} {{SS}} | ||
{{Brain abscess}} | {{Brain abscess}} | ||
== | ==Overview== | ||
The treatment of brain abscess includes prompt administration of antimicrobial therapy upon suspicion and occasionally drainage to reduce the mass effect. Empiric antimicrobial therapy among otherwise healthy individuals includes [[metronidazole]] and either [[cefotaxime]] or [[ceftriaxone]]. Patients with co-morbidities may require alternative antimicrobial therapies. Administration of steroid therapy is generally not recommended and is only indicated among patients who have brain abscesses with mass effect. | |||
==Medical Therapy== | |||
*Prompt administration of antimicrobial therapy is indicated among all patients with brain abscesses. | |||
*Neurosurgery should always be consulted upon diagnosis. The decision of whether to surgically drain, aspirate, or simply administer antimicrobial therapy depends on the number of abscesses, their size, and their location. To learn more about indications of surgical vs. aspiration drainage, click [[Brain abscess surgery|'''here''']]. | |||
*Stereotactic needle biopsy can be performed to obtain tissues for cultures. | |||
*A follow-up head CT scan or MRI is usually indicated at 2-4 weeks of follow-up. The improvement on imaging is often delayed compared to clinical improvement. | |||
==Antimicrobial Regimen== | |||
{{ID-Brain abscess}} | |||
==Other Pharmacologic Agents== | |||
===Steroids=== | |||
*Administration of glucocorticoids is generally not recommended. However, glucorticoids are only indicated when the brain abscess has a mass effect, as suggested by findings on imaging. | |||
*Steroid regimen: | |||
:*Preferred regimen: [[Dexamethasone]] 10 mg IV loading dose {{then}} 4 mg q6h until the mass effect is no longer observed on imaging. | |||
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==References== | ==References== | ||
{{ | {{reflist|2}} | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Up-To-Date]] | |||
[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:Neurosurgery]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Infectious disease]] | [[Category:Infectious disease]] | ||
Latest revision as of 20:40, 29 July 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sheng Shi, M.D. [2]
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Overview
The treatment of brain abscess includes prompt administration of antimicrobial therapy upon suspicion and occasionally drainage to reduce the mass effect. Empiric antimicrobial therapy among otherwise healthy individuals includes metronidazole and either cefotaxime or ceftriaxone. Patients with co-morbidities may require alternative antimicrobial therapies. Administration of steroid therapy is generally not recommended and is only indicated among patients who have brain abscesses with mass effect.
Medical Therapy
- Prompt administration of antimicrobial therapy is indicated among all patients with brain abscesses.
- Neurosurgery should always be consulted upon diagnosis. The decision of whether to surgically drain, aspirate, or simply administer antimicrobial therapy depends on the number of abscesses, their size, and their location. To learn more about indications of surgical vs. aspiration drainage, click here.
- Stereotactic needle biopsy can be performed to obtain tissues for cultures.
- A follow-up head CT scan or MRI is usually indicated at 2-4 weeks of follow-up. The improvement on imaging is often delayed compared to clinical improvement.
Antimicrobial Regimen
- Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.
- 1.1 Brain abscess in otherwise healthy patients
- Preferred regimen (1): (Cefotaxime 8–12 g/day IV q4–6h 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 8–12 g/day q4–6h 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 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h OR Cefepime 2 g IV q12h) AND Vancomycin 30–45 mg/kg/day q8–12h
- 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 10–20 mg/kg/day q6–12h
- 1.2.5 Bacterial endocarditis
- Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h AND Gentamicin 5 mg/kg/day IV q8h
- 1.2.6 Congenital heart disease
- Preferred regimen (1): Cefotaxime 8–12 g/day q4–6h
- Preferred regimen (2): Ceftriaxone 4 g/day q12h
- 1.2.7 Transplant recipients
- Preferred regimen (1): (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h AND Voriconazole 8 mg/kg/day q12h AND (TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h)
- 1.2.8 Patients with HIV/AIDS
- Preferred regimen (1): (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd
- 1.2.9 Staphylococcus aureus coverage
- Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h
- 1.2.10 Mycobacterium tuberculosis coverage
- Preferred regimen: Isoniazid 300 mg qd AND Rifampin 600 mg qd AND Pyrazinamide 15–30 mg qd AND Ethambutol 15 mg/kg/day qd
- Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.
- 2.1 Bacteria
- 2.1.1 Actinomyces
- Preferred regimen: Penicillin G 4 MU IV q4h
- Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h
- 2.1.2 Bacteroides fragilis
- Preferred regimen: Metronidazole 30 mg/kg/day IV q6h
- Alternative regimen: Clindamycin 2400–4800 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 6–8 g/day IV q6–8h
- Alternative regimen (2): TMP-SMZ 10–20 mg/kg/day q6–12h
- Alternative regimen (3): Ciprofloxacin 800–1200 mg/day IV q8–12h
- Alternative regimen (4): Meropenem 2 g IV q8h
- 2.1.4 Fusobacterium
- Preferred regimen: Metronidazole 30 mg/kg/day q6h
- Alternative regimen (1): Clindamycin 2400–4800 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 6–8 g/day IV q6–8h
- Alternative regimen (2): TMP-SMZ 10–20 mg/kg/day q6–12h
- 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 10–20 mg/kg/day q6–12h
- 2.1.7 Nocardia
- Preferred regimen (1): TMP-SMZ 10–20 mg/kg/day q6–12h
- Preferred regimen (2): Sulfadiazine 4–6 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 2400–4800 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 6–8 g/day IV q6–8h
- Alternative regimen (2): Ciprofloxacin 800–1200 mg/day IV q8–12h
- Alternative regimen (3): Meropenem 2 g IV q8h
- 2.1.10 Staphylococcus aureus, methicillin-resistant (MRSA)
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
- Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 4–6 weeks
- Alternative regimen (2):TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 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 300–450 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 30–45 mg/kg/day IV q8–12h
- 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 30–45 mg/kg/day IV q8–12h
- 2.2 Fungi
- 2.2.1 Aspergillus
- Preferred regimen: Voriconazole 8 mg/kg/day q12h
- Alternative regimen (1): Amphotericin B deoxycholate 0.6–1.0 mg/kg/day IV q24h
- Alternative regimen (2): Amphotericin B lipid complex 5 mg/kg/day IV q24h
- Alternative regimen (3): Itraconazole 400–600 mg/day IV q12h
- Alternative regimen (4): Posaconazole 800 mg/kg/day IV q6–12h
- 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 400–800 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 400–800 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 q6–12h
- 2.2.5 Pseudallescheria boydii (Scedosporium apiospermum)
- Preferred regimen: Voriconazole 8 mg/kg/day q12h
- Alternative regimen (1): Itraconazole 400–600 mg/day IV q12h
- Alternative regimen (2):Posaconazole 800 mg/kg/day IV q6–12h
- 2.3 Protozoa
- 2.3.1 Toxoplasma gondii
- Preferred regimen: Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd
- Alternative regimen (1): Pyrimethamine 25–100 mg/day qd AND Clindamycin 2400–4800 mg/day IV q6h
- Alternative regimen (2): Pyrimethamine 25–100 mg/day qd AND (Azithromycin 1200–1500 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 10–20 mg/kg/day q6–12h
Other Pharmacologic Agents
Steroids
- Administration of glucocorticoids is generally not recommended. However, glucorticoids are only indicated when the brain abscess has a mass effect, as suggested by findings on imaging.
- Steroid regimen:
- Preferred regimen: Dexamethasone 10 mg IV loading dose THEN 4 mg q6h until the mass effect is no longer observed on imaging.
References
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
- ↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.