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• Septic thrombosis of cavernous or dural venous sinus

• Empiric antimicrobial therapy

• Preferred regimen: (Nafcillin 2 g IV q4h or Oxacillin 2 g IV q4h) AND (Ceftriaxone 2 g IV q12h or Cefotaxime 8–12 g/day IV q4–6h) AND Metronidazole 7.5 mg/kg IV q6h

Note (1): Vancomycin 30–45 mg/kg IV q8–12h could be substituted for nafcillin or oxacillin if the risk of MRSA is high.

Note (2): The optimal duration of therapy remains unclear. A 3– to 4–week course of treatment is usually recommended.

• Specific considerations

• Cavernous sinus

• Preferred regimen: Vancomycin 30–45 mg/kg IV q8–12h AND (Ceftriaxone 2 g IV q12h or Cefotaxime 8–12 g/day IV q4–6h) AND Metronidazole 7.5 mg/kg IV q6h

Note: Daptomycin 8–12 mg/kg IV q24h OR Linezolid 600 mg IV q12h could be considered for patients unable to tolerate vancomycin.

• Lateral sinus

• Preferred regimen: Cefepime 2 g IV q8h AND Metronidazole 500 mg IV q8h AND Vancomycin 15-20 IV mg/kg
• Alternative regimen: Meropenem 1-2 g IV q8h AND Linezolid 600 mg IV q12h

• Superior sagittal sinus

• Preferred regimen: Ceftriaxone 2 g IV q12h AND Vancomycin 15–20 mg/kg AND Dexamethasone
• Alternative regimen: Meropenem 1–2 g IV q8h AND Vancomycin 15–20 mg/kg AND Dexamethasone

• Pathogen-directed antimicrobial therapy

• Staphylococcus aureus, methicillin-resistant (MRSA)

• Preferred regimen: Vancomycin 15–20 mg/kg/dose IV q8–12h for 4–6 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 (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible.

Note (2): Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin.