Brain abscess medical therapy

Revision as of 01:27, 29 January 2014 by ShiSheng (talk | contribs) (/* Bactria Brain Abscess Adapted from Sanford Guide to Antimicrobial Therapy (2010); and J Neurosci Rural Pract. 2013 August; 4(Suppl 1): S67–S81Carpenter D, Jackson T, Hanley MR (1987) Protein kinase Cs. Coping with a growing family. Nature 325 (700...)
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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).
  • 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[1]

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

  1. Carpenter D, Jackson T, Hanley MR (1987) Protein kinase Cs. Coping with a growing family. Nature 325 (7000):107-8.DOI:10.1038/325107a0 PMID: 3808066


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