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Subdural empyema ⇧ Return to Top ⇧

• Subdural empyema

• Causative pathogens

• 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

• Less common

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

• Empiric antimicrobial therapy

• Infants < 1 month

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

• 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)

• 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)

• Adults < 55 years

• Preferred regimen: Vancomycin 2 g/day IV q12h AND (Cefotaxime 12 g/day IV q4h OR Ceftriaxone 4 g/day IV q12h OR Cefepime 6 g/day IV q8h)

• Adults ≥ 55 years, alcoholics, or with debilitating illness

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h AND Vancomycin 2 g/day IV q12h AND (Cefotaxime 12 g/day IV q4h OR Ceftriaxone 4 g/day IV q12h OR Cefepime 6 g/day IV q8h)

• Impaired cell-mediated immunity or hospital-acquired, post-neurosurgery, or post-traumatic meningitis (pediatric)

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h AND Vancomycin 60 mg/kg/day IV q6h AND (Ceftazidime 150 mg/kg/day IV q8h OR Meropenem 20 mg/kg/day IV q8h)

• Impaired cell-mediated immunity or hospital-acquired, post-neurosurgery, or post-traumatic meningitis (adult)

• Preferred regimen: Ampicillin 12 g/day IV q4h AND Vancomycin 2 g/day IV q12h AND (Ceftazidime 6 g/day IV q8h OR Meropenem 3 g/day IV q8h)

Note (1): The choice of antimicrobial agent should be based on Gram stain results and the likely causative microorganisms.

Note (2): Metronidazole is recommended if anaerobes are suspected. For infection likely caused by aerobic gram-negative bacilli, empirical therapy with Cefepime, Ceftazidime, or Meropenem is appropriate, pending microorganism identification and in vitro susceptibility testing. Metronidazole is not necessary for antianaerobic activity if meropenem is used.

Note (3): 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.

Note (4): Consider adjunctive medications including prophylactic anticonvulsants, corticosteroids, and mannitol if indicated.