Epidural abscess medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]; Anthony Gallo, B.S. [3]
Overview
Epidural abscess is a medical emergency and requires prompt treatment. The treatment of epidural abscess generally involves a combined medical and surgical approach. Antimicrobial therapy for intracranial epidural abscess includes metronidazole, a third generation cephalosporin, and either penicillin or vancomycin. Antimicrobial therapy for spinal epidural abscess includes (vancomycin, (cefepime, ceftazidime, or meropenem). Patients with tuberculous epidural abscess must receive a 12-month course of antituberculous therapy.
Medical Therapy
The treatment of epidural abscess generally involves a combined medical and surgical approach. Therapy of epidural abscess, either intracranial or spinal, should begin with a combination of surgical drainage and prolonged systemic antibiotics (6-12 weeks, IV followed by PO).[1] Due to the importance of preoperative neurologic status, along with the unpredictable progression of neurologic impairment, for the neurological outcome of the patient, the following procedures should occur as early as possible:[2][3]
- Intracranial epidural abscess
- Burr hole placement
- Crainotomy
- Spinal epidural abscess
- Decompressinve laminectomy
- Debridement of infected tissues
However, in certain clinical scenarios, medical therapy may be the only treatment indicated for that particular case, these include:
- Decompressive laminectomy declined by the patient
- High operative risk
- Paralysis which is unlikely reversible, due to being present for > 24 to 36 hours
- Panspinal infection
In rare cases, patients presenting with minor weakness and no neurologic deficit related to the abscess have recovered without surgical treatment, exclusively following antimicrobial therapy.[4] The conservative approach in treating epidural abscess includes:
- Antimicrobial therapy
- Close neurologic monitoring strategy, defined before treatment initiation
- Follow-up MRI to evaluate the status of the abscess and confirm its resolution
- Immediate neurosurgery in cases of neurologic deterioration
The indication for a specific antibiotic should be determined by the results of blood cultures or a CT-guided aspiration of the abscess. However, until blood culture results are obtained, the patient should be on empirical antibiotic therapy. The efficacy of the antibiotic treatment, as well as its duration, may be determined by monitoring the evolution of the erythrocyte sedimentation rate , C-reactive protein, and pain, while monitoring for radiographic changes.[1]
Intracranial Epidural Abscess
The empiric antibiotic therapy for this type of abscess is similar to the one used for subdural empyema and should be continued for 3 to 6 weeks followingsurgery, or longer in case of osteomyelitis.[5] This includes medical therapies against:[2]
This regimen must include:[6][1]
- Penicillin with anti-staphylococcal activity
- Vancomycin (in case of suspicion of MRSA)
- Third-generation cephalosporin
- Metronidazole
Spinal Epidural Abscess
Initial antibiotic therapy for spinal epidural [abscess]] should target:
- Staphylococci
- Aerobic Gram negative bacilli, (particularly in patients with history of IV drug use or spinal procedures)
The treatment should last for 4-6 weeks, or longer (8 weeks maximum), to prevent osteomyelitis.[7] Therefore, the empirical antibiotic regimens for intracranial epidural abscess may also be applied to spinal epidural abscess.
Antimicrobial Regimen
- 1.1 Empiric antimicrobial therapy
- Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks AND Ceftriaxone 2 g IV q24h for 2–4 weeks, then PO to complete 6–8 weeks
- Note (1): Decompressive laminectomy in conjunction with long-term antibiotic therapy tailored to culture results is required.
- Note (2): For critically ill patients, a loading dose of Vancomycin 20–25 mg/kg may be considered.
- 1.2 Pathogen-directed antimicrobial therapy
- 1.2.1 Penicillin-susceptible Staphylococcus aureus or Streptococcus
- Preferred regimen: Penicillin G 4 MU IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
- 1.2.2 Methicillin-susceptible Staphylococcus aureus or Streptococcus
- Preferred regimen (1): Cefazolin 2 g IV q8h for 2–4 weeks THEN PO to complete 6–8 weeks
- Preferred regimen (2): Nafcillin 2 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
- Preferred regimen (3): Oxacillin 2 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
- Alternative regimen: Clindamycin 600 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks
- 1.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks
- Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
- Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h OR Linezolid 10 mg/kg/dose PO/IV q8h
- Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin in adult patients.
- 1.2.4 Streptococcus
- Preferred regimen (1): Penicillin G 3–4 MU IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
- Preferred regimen (2): Ampicillin 2 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
- 1.2.5 Enterococcus
- Preferred regimen (1): Penicillin G 3–4 MU IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
- Preferred regimen (2): Ampicillin 2 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
- 1.2.6 Enterobacteriaceae
- Preferred regimen (1): Ceftriaxone 1–2 g IV q12h for 2–4 weeks THEN PO to complete 6–8 weeks
- Preferred regimen (2): Cefotaxime 2 g IV q6–8h for 2–4 weeks THEN PO to complete 6–8 weeks
- 1.2.7 Gram-negative bacteria
- Preferred regimen (1): Ceftazidime 2 g IV q8h for 2–4 weeks THEN PO to complete 6–8 weeks
- Preferred regimen (2): Cefepime 2 g IV q12h for 2–4 weeks THEN PO to complete 6–8 weeks
- Alternative regimen (1): Ciprofloxacin 400 mg IV q12h for 2–4 weeks THEN PO to complete 6–8 weeks
- Alternative regimen (2): Levofloxacin 750 mg IV q24h for 2–4 weeks THEN PO to complete 6–8 weeks
- Alternative regimen (3): Moxifloxacin 400 mg IV q24h for 2–4 weeks THEN PO to complete 6–8 weeks
- 1.2.8 Anaerobes
- Preferred regimen: Metronidazole 500 mg IV q6h for 2–4 weeks THEN PO to complete 6–8 weeks
- 1.2.9 Staphylococcus, Gram-negative bacteria, and anaerobes (mixed infection)
- Preferred regimen (1): Ampicillin-Sulbactam 3 g IV q6h for 2–4 weeks THEN PO to complete 6–8 weeks
- Preferred regimen (2): Ticarcillin-Clavulanate 3.1 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
- Preferred regimen (3): Piperacillin-Tazobactam 3.375 g IV q4–6h for 2–4 weeks THEN PO to complete 6–8 weeks
- Alternative regimen (1): Imipenem 500–1000 mg IV q6h for 2–4 weeks THEN PO to complete 6–8 weeks
- Alternative regimen (2): Meropenem 1–2 g IV q8h for 2–4 weeks THEN PO to complete 6–8 weeks
References
- ↑ 1.0 1.1 1.2 Grewal, S. (2006). "Epidural abscesses". British Journal of Anaesthesia. 96 (3): 292–302. doi:10.1093/bja/ael006. ISSN 0007-0912.
- ↑ 2.0 2.1 Darouiche, Rabih O. (2006). "Spinal Epidural Abscess". New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 0028-4793.
- ↑ Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM (1992). "Bacterial spinal epidural abscess. Review of 43 cases and literature survey". Medicine (Baltimore). 71 (6): 369–85. PMID 1359381.
- ↑ Wheeler D, Keiser P, Rigamonti D, Keay S (1992). "Medical management of spinal epidural abscesses: case report and review". Clin Infect Dis. 15 (1): 22–7. PMID 1617070.
- ↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0-443-06839-9.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0-443-06839-9.
- ↑ Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.
- ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
- ↑ Darouiche, Rabih O. (2006-11-09). "Spinal epidural abscess". The New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 1533-4406. PMID 17093252.
- ↑ 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.