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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. Metronidazole is not necessary for antianaerobic activity if meropenem is used.

Note (3): For coverage of aerobic Gram-negative bacilli, empiric therapy with Cefepime, Ceftazidime, or Meropenem is appropriate.

Note (4): 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.

Note (5): A longer course of treatment (minimum of 6–8 weeks) may be required if the patient has accompanying osteomyelitis.

Note (6): Consider adjunctive medications including prophylactic anticonvulsants, corticosteroids, and mannitol if clinically indicated.