Sandbox brain abscess

Brain Abscess Adapted from Sanford Guide to Antimicrobial Therapy (2010); and J Neurosci Rural Pract. 2013 August; 4(Suppl 1): S67–S81

Click on the following categories to expand treatment regimens.

Brain Abscess   ▸  Primary Source   ▸  Contiguous Source   ▸  Post-Traumatic   ▸  Post-Surgical   ▸  Metastatic or Cryptogenic   ▸  Haematogenous Abscess   ▸  Immunocompromised

Primary Source Preferred Regimen ▸ Cefotaxime 2 gm IV q4h OR ▸ Ceftriaxone 2 gm IV q12h PLUS ▸ Metronidazole 7.5 mg/kg q6h OR 5 mg/kg IV q12h Alternative Regimen ▸ Penicllin G 3-4 million units IV q4h PLUS ▸ Metronidazole 7.5 mg/kg q6h OR 15 mg/kg IV q12h Contiguous source Preferred Regimen ▸ Metronidazole 500 mg/kg q8h PLUS ▸ Cefotaxime 2 g IV q6h OR ▸ Piperacillin/Tazobactam 4.5 g IV q6h† Post-traumatic Preferred Regimen ▸ Cefotaxime 2 g IV q6h PLUS ▸ Metronidazole 500 mg/kg q8h PLUS OR NOT ▸ Rifampin 10 mg/kg q24h Post-surgical Preferred Regimen ▸ Linezolid 600 mg IV q12h OR ▸ Vancomycin 15 mg/kg loading dose or 10-15 mg/kg q6h followed by 40-60 mg/kg/24 hourly continuously infusion‡ PLUS ▸ Rifampin 10 mg/kg qd PLUS ▸ Meropenem 1.5 g q6h or 2 g q8h OR ▸ Piperacillin/Tazobactam 4.5 g q6h metastatic or cryptogenic Preferred Regimen ▸ Cefataxime 2 g IV q6h PLUS OR NOT ▸ Metronidazole 500 mg q8h OR Ampicillin/Sulbactam 100/50 mg/kg q6h Haematogenous Abscess¶ Preferred Regimen# ▸ Trimethoprim: 3.75-7.5 mg/kg IV/ po q6-12h PLUS ▸ Sulfamethoxazole: 18.75-37.5 mg/kg/day IV/po q6-12h PLUS ▸ Ceftriaxone 2 gm IV q12h Alternative Regimen ▸ Trimethoprim: 3.75-7.5 mg/kg IV/ po q6-12h PLUS ▸ Sulfamethoxazole: 18.75-37.5 mg/kg/day IV/po q6-12h PLUS ▸ Amikacin 7.5 mg/kg q12h PLUS ▸ Imipenem-Cilastatin 500 mg IV q6h Immunocompromised Preferred Regimen(for minimum of 6 wks after resolution of signs) ▸ Pyrimethamine 200 mg po qd then 75 mg/day po PLUS ▸ Sulfadiazine: 1 gm po q6h if <60 kg, 1.5 gm po q6h if •60 kg PLUS ▸ Folinic acid 10–25 mg po qd Alternative Regimen(for 4–6 wks after resolution of signs) ▸ Pyrimethamine 200 mg po qd then 75 mg/day po PLUS ▸ Folinic acid 10–25 mg po qd PLUS ▸ Clindamycin 600 mg po IV q6h OR ▸ TMP/SMX 5/25 mg/kg po qd or IV bid OR ▸ Atovaquone 750 mg po q6h Suppression therapy ▸ Sulfadiazine: 2-4 g po q6-12h PLUS ▸Pyrimethamine 25-50 mg po qd PLUS ▸ Folinic acid 10–25 mg po qd OR ▸ Trimethoprim-Sulfamethoxazole 5/25 mg/kg po or IV q12h for 30 days

^†:If Pseudomonas aeruginosa is suspected.

^‡:The aim is to keep the serum levels at 15-25mg/L

^¶: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.

^#: If multiorgan involvement some add amikacin 7.5 mg/kg q12h.