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==Medical Therapy==
==Medical Therapy==
Initial treatment includes lowering the [[intracranial pressure]] and administering empiric [[antibiotic]]s.  Stereotactic needle biopsy can be performed to obtain tissues for cultures.
*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''']].
A brain abscess greater than 3 cm in diameter should be considered for surgical drainage if accessible, with an exception of tuberculous brain abscess which is treated with anti-tuberculous agents.
*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.
*Antibiotics: Brain abscesses are usually polymicrobial, with the most common bugs being microaerophilic ''[[streptococci]]'' (viridans) and anaerobic bacteria (bacteroides, anaerobic strep and [[fusobacterium]]).
:* ''[[S. aureus]]'', and enterobacteriacae are also seen.
:* Bugs associated with [[trauma]] include ''[[S. aureus]]'' and ''[[clostridium]]'' sp.
:* Empiric Rx usually starts with high-dose PCN (10 – 20 million units / d), [[metronidazole]], +/- a 3rd gen [[cephalosporin]].
::* Even if the abscess is associated with a dental procedure and other organisms are considered ([[actinomyces]] sp.) they generally respond to the above Rx.
::* If extending from an [[otitis]], empiric Rx should also cover ''[[pseudomonas]]'' and enterobacteriacaea.
::* If hematogenously spread, coverage depends on the original bug.
*The penetration of abx into an abscess does not necessarily equate with their penetration into the [[CSF]] (the blood-brain barrier is not the same as the blood-CSF barrier).
:* Drugs like [[vancomycin]], which have poor [[CSF]] levels (<10% of serum) have been shown to have good abscess levels (90% of serum).
* Most patients are treated parenterally for at least 8w.
:* Some authors also recommend an additional 2 – 3 month course of oral abx to clear up any ‘residual’ infection and to prevent relapses.
:* One study actually suggests that, when combined with surgical excision, 3w may be adequate.
:* Other studies have reported good outcomes with abx alone in patients with small lesions (<2cm), in well vascularized areas (cortex), who were poor surgical candidates.
* There have not been any studies reporting benefit from intra-thecal or intra-abscess abx.
* There seems to be consensus on obtaining q 2 – 4w f/u [[CT]]/[[MRI]] scans to document resolution.
 
==== Adjuvants ====
:* Although steroids have not been studies in well-designed trials, many authors use them in patients with elevated ICP.
:* Some animal studies suggest interference with granulation tissue formation and bacterial clearance.
:* [[Anticonvulsant]]s are recommended prophylactically for the 1st 3m, though the data supporting this is lacking.<ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages =  }}</ref>


==Antimicrobial Regimen==
==Antimicrobial Regimen==

Revision as of 16:31, 28 August 2015

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 involves the reduction of intracranial pressure, localization of the infection spread, and administration of antimicrobial therapy. Empiric antimicrobial therapy among otherwise healthy individuals includes Metronidazole and either Cefotaxime or Ceftriaxone. Patients with co-morbidities may require alternative antimicrobial therapies.

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

  • 1. Empiric antimicrobial therapy[1][2]
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
  • 1.2 Brain abscess with comorbidities
  • 1.2.1 Otitis media, mastoiditis, or sinusitis
  • 1.2.2 Dental infection
  • 1.2.3 Penetrating trauma or post-neurosurgy
  • 1.2.4 Lung abscess, empyema, or bronchiectasis
  • 1.2.5 Bacterial endocarditis
  • 1.2.6 Congenital heart disease
  • 1.2.7 Transplant recipients
  • 1.2.8 Patients with HIV/AIDS
  • 1.2.9 Staphylococcus aureus coverage
  • Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h
  • 1.2.10 Mycobacterium tuberculosis coverage
  • 2. Pathogen-directed antimicrobial therapy[3][4][5]
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
  • 2.1.2 Bacteroides fragilis
  • 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
  • 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
  • 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
  • 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
  • 2.2.3 Cryptococcus neoformans
  • 2.2.4 Mucorales
  • 2.2.5 Pseudallescheria boydii (Scedosporium apiospermum)
  • 2.3 Protozoa
  • 2.3.1 Toxoplasma gondii

References

  1. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  2. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  3. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  4. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  5. ↑ 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.
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