Sandbox brain abscess

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

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Overview

Treatment of brain abscess requires a multidisciplinary approach to delineate extent of infection, plan stereotactic trajectory, aspirate purulent materials, lower intracranial pressure, identify causative pathogen, and administer appropriate antibiotics.

Antimicrobial Therapy – Empiric Therapy

Preferred regimen

Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h AND Metronidazole 30 mg/kg/day q6h

Alternative regimen

Meropenem 6 g/day q8h

Transplant recipients

Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h AND Metronidazole 30 mg/kg/day q6h AND Voriconazole 8 mg/kg/day q12h AND TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h

Patients with HIV/AIDS

Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h AND Metronidazole 30 mg/kg/day q6h AND Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd

Staphylococcus aureus coverage

Vancomycin 30–45 mg/kg/day q8–12h

Mycobacterium tuberculosis coverage

Vancomycin 30–45 mg/kg/day q8–12h AND Isoniazid 300 mg qd AND Rifampin 600 mg qd AND Pyrazinamide 15–30 mg qd AND Ethambutol 15 mg/kg/day qd

Antimicrobial Therapy – Pathogen-Based Therapy

Actinomyces

Penicillin G 24 MU q4h

Bacteroides fragilis

Metronidazole 30 mg/kg/day q6h

Enterobacteriaceae

Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h

Fusobacterium

Metronidazole 30 mg/kg/day q6h

Haemophilus

Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h

Listeria monocytogenes

Ampicillin 12 g/day q4h OR Penicillin G 24 MU q4h

Nocardia

TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h

Prevotella melaninogenica

Metronidazole 30 mg/kg/day q6h

Pseudomonas aeruginosa

Ceftazidime 6 g/day q8h OR Cefepime 6 g/day q8h

Methicillin-Sensitive Staphylococcus aureus

Nafcillin 12 g/day q4h OR Oxacillin 12 g/day q4h

Methicillin-resistant Staphylococcus aureus

Vancomycin 30–45 mg/kg/day q8–12h

Streptococcus anginosus and other Streptococci

Penicillin G 24 MU q4h

Aspergillus

Voriconazole 8 mg/kg/day q12h

Candida

Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h

Cryptococcus neoformans

Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h

Mucorales

Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h

Pseudallescheria boydii (Scedosporium apiospermum)

Voriconazole 8 mg/kg/day q12h

Toxoplasma gondii

Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd