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==Brain Abscess <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from Sanford Guide to Antimicrobial Therapy (2010); and
__NOTOC__
{{CMG}}
{{Brain abscess}}


J Neurosci Rural Pract. 2013 August; 4(Suppl 1): S67–S81<ref name="pmid3808066">Carpenter D, Jackson T, Hanley MR (1987) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3808066 Protein kinase Cs. Coping with a growing family.] ''Nature'' 325 (7000):107-8. [http://dx.doi.org/10.1038/325107a0 DOI:10.1038/325107a0] PMID: [http://pubmed.gov/3808066 3808066]</ref></SMALL></SMALL></SMALL></SMALL></SMALL>
==Overview==
Treatment of brain abscess requires a multidisciplinary approach to delineate extent of infection, plan stereotactic trajectory, aspirate [[purulent]] materials, lower [[intracranial pressure]], identify causative pathogen, and administer appropriate [[antibiotics]].


<font color="#FF4C4C">'''Click on the following categories to expand treatment regimens.'''</font>
==Antimicrobial Therapy – Empiric Therapy==
{{rx|Preferred regimen}}
* [[Cefotaxime]] 8–12 g/day q4–6h {{or}} [[Ceftriaxone]] 4 g/day q12h {{and}} 
* [[Metronidazole]] 30 mg/kg/day q6h
</li>
{{rx|Alternative regimen}}
* [[Meropenem]] 6 g/day q8h
</li>
{{rx|Transplant recipients}}
* [[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
</li>
{{rx|Patients with HIV/AIDS}}
* [[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
</li>
{{rx|Staphylococcus aureus coverage}}
* [[Vancomycin]] 30–45 mg/kg/day q8–12h
</li>
{{rx|Mycobacterium tuberculosis coverage}}
* [[Isoniazid]] 300 mg qd {{and}} 
* [[Rifampin]] 600 mg qd {{and}} 
* [[Pyrazinamide]] 15–30 mg qd {{and}} 
* [[Ethambutol]] 15 mg/kg/day qd
</li>


{|
==Antimicrobial Therapy – Pathogen-Based Therapy==
| valign=top |
{{rx|Actinomyces}}
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
* [[Penicillin G]] 24 MU q4h
<font color="#FFF">
</li>
'''Brain Abscess'''
{{rx|Bacteroides fragilis}}
</font>
* [[Metronidazole]] 30 mg/kg/day q6h
</div>
</li>
{{rx|Enterobacteriaceae}}
* [[Cefotaxime]] 8–12 g/day q4–6h {{or}} [[Ceftriaxone]] 4 g/day q12h
</li>
{{rx|Fusobacterium}}
* [[Metronidazole]] 30 mg/kg/day q6h
</li>
{{rx|Haemophilus}}
* [[Cefotaxime]] 8–12 g/day q4–6h {{or}} [[Ceftriaxone]] 4 g/day q12h
</li>
{{rx|Listeria monocytogenes}}
* [[Ampicillin]] 12 g/day q4h {{or}} [[Penicillin G]] 24 MU q4h
</li>
{{rx|Nocardia}}
* [[TMP-SMZ]] 10–20 mg/kg/day q6–12h {{or}} [[Sulfadiazine]] 4–6 g/day q6h
</li>
{{rx|Prevotella melaninogenica}}
* [[Metronidazole]] 30 mg/kg/day q6h
</li>
{{rx|Pseudomonas aeruginosa}}
* [[Ceftazidime]] 6 g/day q8h {{or}} [[Cefepime]] 6 g/day q8h
</li>
{{rx|Methicillin-sensitive Staphylococcus aureus}}
* [[Nafcillin]] 12 g/day q4h {{or}} [[Oxacillin]] 12 g/day q4h
</li>
{{rx|Methicillin-resistant Staphylococcus aureus}}
* [[Vancomycin]] 30–45 mg/kg/day q8–12h
</li>
{{rx|Streptococcus anginosus and other streptococci}}
* [[Penicillin G]] 24 MU q4h
</li>
{{rx|Aspergillus}}
* [[Voriconazole]] 8 mg/kg/day q12h
</li>
{{rx|Candida}}
* [[Amphotericin B]] lipid complex 5 mg/kd/day q24h {{or}} [[Amphotericin B]] deoxycholate 15 mg/kg/day q8h
</li>
{{rx|Cryptococcus neoformans}}
* [[Amphotericin B]] lipid complex 5 mg/kd/day q24h {{or}} [[Amphotericin B]] deoxycholate 15 mg/kg/day q8h
</li>
{{rx|Mucorales}}
* [[Amphotericin B]] lipid complex 5 mg/kd/day q24h {{or}} [[Amphotericin B]] deoxycholate 15 mg/kg/day q8h
</li>
{{rx|Pseudallescheria boydii (Scedosporium apiospermum)}}
* [[Voriconazole]] 8 mg/kg/day q12h
</li>
{{rx|Toxoplasma gondii}}
* [[Sulfadiazine]] 4–6 g/day q6h {{and}} 
* [[Pyrimethamine]] 25–100 mg/day qd
</li>


<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
==References==
<font color="#FFF">
{{Reflist|2}}
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Primary Source'''
</font>
</div>


<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
[[Category:Disease]]
<font color="#FFF">
[[Category:Neurology]]
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Contiguous Source'''
</font>
</div>


<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
[[Category:Neurosurgery]]
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Post-Traumatic'''
</font>
</div>
 
<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Post-Surgical'''
</font>
</div>
 
<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Metastatic or Cryptogenic'''
</font>
</div>
 
<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Haematogenous Abscess'''
</font>
</div>
 
<div class="mw-customtoggle-table07" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Immunocompromised'''
</font>
</div>
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center |{{fontcolor|#FFF|Primary Source}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] 2 gm IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone ]] 2 gm IV q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 7.5 mg/kg q6h ''OR'' 5 mg/kg IV q12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Penicllin G]] 3-4 million units IV q4h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 7.5 mg/kg q6h ''OR'' 15 mg/kg IV q12h'''''
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center |{{fontcolor|#FFF|Contiguous source}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg/kg q8h
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q6h'''''<BR>''OR''<BR>▸ '''''[[Piperacillin]]/[[Tazobactam]] 4.5 g IV q6h'''''<sup>†</sup>
 
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center |{{fontcolor|#FFF|Post-traumatic}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg/kg q8h
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS OR NOT
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rifampin]] 10 mg/kg q24h
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center |{{fontcolor|#FFF|Post-surgical}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Linezolid]] 600 mg IV q12h'''''<BR>''OR''<BR>▸ '''''[[Vancomycin]] 15 mg/kg loading dose or 10-15 mg/kg q6h followed by 40-60 mg/kg/24 hourly continuously infusion'''''<sup>‡</sup>
|-
 
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
 
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rifampin]] 10 mg/kg qd
|-
 
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1.5 g q6h or 2 g q8h'''''<BR>''OR''<BR>▸ '''''[[Piperacillin/Tazobactam]] 4.5 g q6h'''''
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center |{{fontcolor|#FFF|metastatic or cryptogenic}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefataxime]] 2 g IV q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS OR NOT
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg q8h <BR>''OR''<BR>[[Ampicillin/Sulbactam]] 100/50 mg/kg q6h'''''
|-
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center |{{fontcolor|#FFF|Haematogenous Abscess}}<sup>¶</sup>
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen<sup>#</sup>'''''
 
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Trimethoprim]]: 3.75-7.5 mg/kg IV/ po q6-12h
 
|-
 
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
 
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Sulfamethoxazole]]: 18.75-37.5 mg/kg/day IV/po q6-12h
|-
 
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
 
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Trimethoprim]]: 3.75-7.5 mg/kg IV/ po q6-12h
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Sulfamethoxazole]]: 18.75-37.5 mg/kg/day IV/po q6-12h
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amikacin]] 7.5 mg/kg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Imipenem-Cilastatin]] 500 mg IV q6h
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table07" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center |{{fontcolor|#FFF|Immunocompromised}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen(<small><small><small>for minimum of 6  wks after resolution of signs</small></small></small>)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Pyrimethamine]] 200 mg po qd then 75 mg/day po'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Sulfadiazine]]: 1 gm po q6h if <60 kg, 1.5 gm po q6h if •60 kg
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Folinic acid]] 10–25 mg po qd
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen(<small><small><small>for 4–6  wks after resolution of signs</small></small></small>)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Pyrimethamine]] 200 mg po qd then 75 mg/day po'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Folinic acid]] 10–25 mg po qd
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clindamycin]] 600 mg po IV q6h'''''<BR>''OR''<BR>▸ '''''[[TMP]]/[[SMX]] 5/25 mg/kg po qd or IV bid'''''<BR>''OR''<BR>▸ '''''[[Atovaquone]] 750 mg po q6h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Suppression therapy'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Sulfadiazine]]: 2-4 g po q6-12h'''''<BR>''PLUS''<BR>▸'''''[[Pyrimethamine]] 25-50 mg po qd'''''<BR>''PLUS''<BR>▸ '''''[[Folinic acid]] 10–25 mg po qd'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Trimethoprim-Sulfamethoxazole ]] 5/25 mg/kg po or IV q12h for 30 days '''''
|-
|}
|}
|}
<small><small><small><small><sup>†</sup>:If Pseudomonas aeruginosa is suspected.</small></small></small><small>
 
<small><small><small><small><sup>‡</sup>:The aim is  to keep the  serum levels at 15-25mg/L</small></small></small><small>
 
<small><small><small><small><sup>¶</sup>:After 3-6 wks of IV therapy, switch to po therapy. Immunocompetent pts: TMP-SMX, minocycline or AM-CL x 3+months. Immunocompromised pts: Treat with 2 drugs for at least one year.</small></small></small><small>
 
<small><small><small><small><sup>#</sup>: If multiorgan involvement some add amikacin 7.5 mg/kg q12h.

Latest revision as of 18:41, 18 September 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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