Brain abscess medical therapy

Jump to navigation Jump to search

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sheng Shi, M.D. [2]

Abscess Main Page

Brain abscess Microchapters

Home

Patient Information

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating Brain abscess from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Brain abscess medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Brain abscess medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Brain abscess medical therapy

CDC on Brain abscess medical therapy

Brain abscess medical therapy in the news

Blogs on Brain abscess medical therapy

Directions to Hospitals Treating Brain abscess

Risk calculators and risk factors for Brain abscess medical therapy

Overview

The treatment of brain abscess includes prompt administration of antimicrobial therapy upon suspicion and occasionally drainage to reduce the mass effect. Empiric antimicrobial therapy among otherwise healthy individuals includes Metronidazole and either Cefotaxime or Ceftriaxone. Patients with co-morbidities may require alternative antimicrobial therapies. Administration of steroid therapy is generally not recommended and is only indicated among patients who have brain abscesses with mass effect.

Medical Therapy

  • Prompt administration of antimicrobial therapy is indicated among all patients with brain abscesses.
  • Neurosurgery should always be consulted upon diagnosis. The decision of whether to surgically drain, aspirate, or simply administer antimicrobial therapy depends on the number of abscesses, their size, and their location. To learn more about indications of surgical vs. aspiration drainage, click here.
  • Stereotactic needle biopsy can be performed to obtain tissues for cultures.
  • A follow-up head CT scan or MRI is usually indicated at 2-4 weeks of follow-up. The improvement on imaging is often delayed compared to clinical improvement.

Antimicrobial Regimen

  • 1. Empiric antimicrobial therapy[1][2]
Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.
  • 1.1 Brain abscess in otherwise healthy patients
  • 1.2 Brain abscess with comorbidities
  • 1.2.1 Otitis media, mastoiditis, or sinusitis
  • 1.2.2 Dental infection
  • 1.2.3 Penetrating trauma or post-neurosurgy
  • 1.2.4 Lung abscess, empyema, or bronchiectasis
  • 1.2.5 Bacterial endocarditis
  • 1.2.6 Congenital heart disease
  • 1.2.7 Transplant recipients
  • 1.2.8 Patients with HIV/AIDS
  • 1.2.9 Staphylococcus aureus coverage
  • Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h
  • 1.2.10 Mycobacterium tuberculosis coverage
  • 2. Pathogen-directed antimicrobial therapy[3][4][5]
Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.
  • 2.1 Bacteria
  • 2.1.1 Actinomyces
  • 2.1.2 Bacteroides fragilis
  • 2.1.3 Enterobacteriaceae
  • Preferred regimen (1): Cefotaxime 2 g IV q4-6h
  • Preferred regimen (2): Ceftriaxone 2 g IV q12h
  • Preferred regimen (3): Cefepime 2 g IV q12h
  • Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
  • Alternative regimen (2): TMP-SMZ 10–20 mg/kg/day q6–12h
  • Alternative regimen (3): Ciprofloxacin 800–1200 mg/day IV q8–12h
  • Alternative regimen (4): Meropenem 2 g IV q8h
  • 2.1.4 Fusobacterium
  • 2.1.5 Haemophilus
  • Preferred regimen (1): Cefotaxime 2 g IV q4-6h
  • Preferred regimen (2): Ceftriaxone 2 g IV q12h
  • Preferred regimen (3): Cefepime 2 g IV q12h
  • Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
  • Alternative regimen (2): TMP-SMZ 10–20 mg/kg/day q6–12h
  • 2.1.6 Listeria monocytogenes
  • Preferred regimen (1): Ampicillin 12 g/day q4h
  • Preferred regimen (2): Penicillin G 4 MU IV q4h
  • Alternative regimen (1): TMP-SMZ 10–20 mg/kg/day q6–12h
  • 2.1.7 Nocardia
  • Preferred regimen (1): TMP-SMZ 10–20 mg/kg/day q6–12h
  • Preferred regimen (2): Sulfadiazine 4–6 g/day q6h
  • Alternative regimen (1): Meropenem 2 g IV q8h
  • Alternative regimen (2): Cefotaxime 2 g IV q4-6h
  • Alternative regimen (3): Ceftriaxone 2 g IV q12h
  • Alternative regimen (4): Amikacin 15 mg/kg/day IV q8h
  • 2.1.8 Prevotella melaninogenica
  • 2.1.9 Pseudomonas aeruginosa
  • Preferred regimen (1): Ceftazidime 6 g/day q8h
  • Preferred regimen (2): Cefepime 6 g/day q8h
  • Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
  • Alternative regimen (2): Ciprofloxacin 800–1200 mg/day IV q8–12h
  • Alternative regimen (3): Meropenem 2 g IV q8h
  • 2.1.10 Staphylococcus aureus, methicillin-resistant (MRSA)
  • Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
  • Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 4–6 weeks
  • Alternative regimen (2):TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
  • Pediatric dose (1): Vancomycin 15 mg/kg/dose IV q6h
  • Pediatric dose (2): Linezolid 10 mg/kg/dose PO/IV q8h
  • Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin.
  • 2.1.11 Staphylococcus aureus, methicillin-susceptible (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4h
  • Preferred regimen (2): Oxacillin 2 g IV q4h
  • Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h
  • 2.1.12 Streptococcus
  • 2.2 Fungi
  • 2.2.1 Aspergillus
  • Preferred regimen: Voriconazole 8 mg/kg/day q12h
  • Alternative regimen (1): Amphotericin B deoxycholate 0.6–1.0 mg/kg/day IV q24h
  • Alternative regimen (2): Amphotericin B lipid complex 5 mg/kg/day IV q24h
  • Alternative regimen (3): Itraconazole 400–600 mg/day IV q12h
  • Alternative regimen (4): Posaconazole 800 mg/kg/day IV q6–12h
  • 2.2.2 Candida
  • 2.2.3 Cryptococcus neoformans
  • 2.2.4 Mucorales
  • 2.2.5 Pseudallescheria boydii (Scedosporium apiospermum)
  • 2.3 Protozoa
  • 2.3.1 Toxoplasma gondii

Other Pharmacologic Agents

Steroids

  • Administration of glucocorticoids is generally not recommended. However, glucorticoids are only indicated when the brain abscess has a mass effect, as suggested by findings on imaging.
  • Steroid regimen:
  • Preferred regimen: Dexamethasone 10 mg IV loading dose THEN 4 mg q6h until the mass effect is no longer observed on imaging.

References

  1. Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  2. Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  3. Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  4. Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  5. Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.