Brain abscess medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Treatment

Treatment is generally a team approach and most reliably depends on obtaining tissue via a stereotactic needle Bx. Although randomized, controlled trials have not been done, the consensus is that abscesses > 3cm should be drained (if accessible).

The treatment includes lowering the increased intracranial pressure and starting intravenous antibiotics (and meanwhile identifying the causative organism mainly by blood culture studies).

Surgical drainage of the abscess remains part of the standard management of bacterial brain abscesses. The location and treatment of the primary lesion also crucial, as is the removal of any foreign material (bone, dirt, bullets, and so forth).

There are a few exceptions to this rule: Haemophilus influenzae meningitis is often associated with subdural effusions that are mistaken for subdural empyemas. These effusions resolve with antibiotics and require no surgical treatment. Tuberculosis can produce brain abscesses that look identical to bacterial abscesses on CT imaging and surgical drainage or aspiration is often necessary to make the diagnosis, but once the diagnosis is made no further surgical intervention is necessary.

• 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.
• Anticonvulsants are recommended prophylactically for the 1st 3m, though the data supporting this is lacking.

Bactria 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/Sulbactam100/50 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

^₳:Mainly from paranasal sinuses,middle ear,dental infection.

^†: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.

Brain Absecss Special Pathogen

Bacteria Brain Abscess   ▸  Actinomyces spp.   ▸  Bacteroides fragilis   ▸  Enterobacteriaceae   ▸  Fusobacterium spp.   ▸  Haemophilus spp.   ▸  Listeria monocytogenes   ▸  Mycobacterium tuberculosis   ▸  Nocardia spp.   ▸  Prevotella melaninogenica   ▸  Pseudomonas aeruginosa   ▸  Staphylococcus aureus   ▸  Streptococcus anginosus

Actinomyces spp. Preferred Regimen ▸ Penicillin G 2 gm IV q4h Alternative Regimen ▸ Clindamycin 600-1200 mg q6h Bacteroides fragilis Preferred Regimen ▸ Metronidazole 500 mg/kg q8h Alternative Regimen ▸ Clindamycin 600-1200 mg q6h Bacteroides fragilis Preferred Regimen ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸Ceftriaxone 2 g IV q12h Alternative Regimen ▸ Aztreonam 6-8 g/day IV q6-8h OR ▸ Trimethoprim-Sulfamethoxazole 10-20 mg/kg q6-12h OR ▸ Fluoroquinolone OR ▸ Meropenem 2 g PO q8h Fusobacterium spp. Preferred Regimen ▸ Penicillin G 4 million U IV q4h Alternative Regimen ▸ Clindamycin 600-1200 mg q6h Haemophilus spp. Preferred Regimen ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸ Ceftriaxone 2 g IV q12h Alternative Regimen ▸ Aztreonam 6-8 g/day IV q6-8h OR ▸ Trimethoprim-Sulfamethoxazole 10-20 mg/kg q6-12h Listeria monocytogenes Preferred Regimen ▸ Ampicillin 2 g IV q4h OR ▸ Penicillin G 4 million U IV q4h Alternative Regimen ▸ Trimethoprim-Sulfamethoxazole 10-20 mg/kg q6-12h Mycobacterium tuberculosis Preferred Regimen ▸ Isoniazid 300 mg PO qd PLUS ▸ Rifampin 600 mg PO qd PLUS ▸ Pyrazinamide 15-30 mg/kg PO qd PLUS OR NOT ▸ Ethambutol 15 mg/kg PO qd Nocardia spp. Preferred Regimen ▸ Trimethoprim-Sulfamethoxazole 10-20 mg/kg IV q6-12h' OR ▸ Sulfadiazine 1-1.5 g PO q6h Alternative Regimen ▸ Minocycline OR ▸ Imipenem OR ▸ Meropenem 2 g PO q8h OR ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸ Ceftriaxone 2 g IV q12h OR ▸ Amikacin 5 mg/kg IV q8h Prevotella melaninogenica Preferred Regimen ▸ Metronidazole 500 mg/kg q8h Alternative Regimen ▸ Clindamycin 600-1200 mg q6h OR ▸ Cefotaxime 2 g IV q8h Pseudomonas aeruginosa Preferred Regimen ▸ Ceftazidime 2 g IV q8h OR ▸ Cefepime 2 g IV q8h Alternative Regimen ▸ Aztreonam 6-8 g/day IV q6-8h OR ▸ Fluoroquinolone OR ▸ Meropenem 2 g IV q8h Staphylococcus aureus;Methicillin-sensitive Preferred Regimen ▸ Nafcillin 1.5-2 g IV q4h OR ▸ Oxacillin 1.5-2 g IV q4h Alternative Regimen ▸ Vancomycin 30-45 mg/kg IV q8-12h Staphylococcus aureus;Methicillin-resistant Preferred Regimen ▸ Vancomycin 30-45 mg/kg IV q8-12h Alternative Regimen ▸ Trimethoprim-sulfamethoxazole 10-20 mg/kg IV q6-12h Streptococcus anginosus (milleri) group, other streptococci Preferred Regimen ▸ Penicillin G 4 million U IV q4h Alternative Regimen ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸ Ceftriaxone 2 g IV q12h OR ▸ Vancomycin 30-45 mg/kg IV q8-12h

Fungal Brain Abscess

Fungal Brain Abscess   ▸  Aspergillus spp.   ▸  Candida spp.   ▸  Cryptococcus neoformans   ▸  Mucorales   ▸  Scedosporium spp.

Aspergillus spp. Preferred Regimen ▸ Voriconazole Load with 6 mg/kg IV q12h for two doses then 4 mg/kg q12h Alternative Regimen ▸ Amphotericin B deoxycholate OR ▸ Liposomal amphotericin B 5 mg/kg IV qd OR ▸ Amphotericin B lipid complex OR ▸ Itraconazole 400 mg IV q12h OR ▸ Posaconazole 200-400 mg q6-12h Candida spp. Preferred Regimen ▸ Amphotericin B deoxycholate OR ▸ Liposomal amphotericin B 5 mg/kg IV qd OR ▸ Amphotericin B lipid complex PLUS ▸ Flucytosine 25 mg/kg PO q6h Alternative Regimen ▸ Fluconazole 400-800 mg IV qd Cryptococcus neoformans ▸Amphotericin B deoxycholate OR ▸ Liposomal amphotericin B 5 mg/kg IV qd OR ▸ Amphotericin B lipid complex PLUS ▸Flucytosine 25 mg/kg PO q6h Alternative Regimen ▸Fluconazole 400-800 mg IV qd Mucorales Preferred Regimen ▸Amphotericin B deoxycholate OR ▸ Liposomal amphotericin B 5 mg/kg IV qd OR ▸ Amphotericin B lipid complex Alternative Regimen ▸ Posaconazole 200-400 mg q6-12h Scedosporium spp. Preferred Regimen ▸ Voriconazole Load with 6 mg/kg IV q12h for two doses then 4 mg/kg q12h Alternative Regimen ▸ Itraconazole 400 mg IV q12h OR ▸ Posaconazole 200-400 mg q6-12h

References

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