Template:ID-Subdural empyema

• Subdural empyema

• 1. Causative pathogens

• 1.1 More common

• Streptococcus milleri
• Other streptococci and enterococci
• Aerobic Gram-negative bacilli (Haemophilus influenzae, Proteus, Escherichia coli, Pseudomonas, Klebsiella, Acinetobacter, Salmonella, Morganella, Eikenella)
• No growth

• 1.2 Less common

• Streptococcus pneumoniae
• Staphylococcus aureus, coagulase-negative staphylococci
• Anaerobic Gram-positive cocci (Veillonella, Peptostreptococcus, others)
• Anaerobic Gram-negative bacilli (Bacteroides, Fusobacterium, Prevotella)

• 2. Empiric antimicrobial therapy

• The choice of antimicrobial agent should be based on Gram stain results and directed against the likely causative microorganisms in the specific clinical setting.
• 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.

• 2.1 Intracranial subdural empyema with unclear source of infection

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

• 2.2 Intracranial subdural empyema associated with sinusitis or otitis media

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

• 2.3 Intracranial subdural empyema after cranial trauma

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

• 2.4 Intracranial subdural empyema after neurosurgical procedures

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

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

• 2.5.1 Infants < 1 month

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h AND Cefotaxime 200 mg/kg/day IV q6h

• 2.5.2 Infants 1–3 months

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

• 2.5.3 Infants > 3 months

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

• 2.6 Spinal subdural empyema

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

• 3. Pathogen-directed antimicrobial therapy

• 3.1 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.