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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.