Brain abscess medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sheng Shi, M.D. [2]
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Overview
Treatment of brain abscess requires a multidisciplinary approach to lower intracranial pressure, delineate extent of infection, evacuate purulent materials, administer appropriate antibiotics, and obtain tissue specimens.
Medical Therapy
Initial treatment includes lowering the intracranial pressure and administering empiric antibiotics. Stereotactic needle biopsy can be performed to obtain tissues for cultures.
A brain abscess greater than 3 cm in diameter should be considered for surgical drainage if accessible, with an exception of tuberculous brain abscess which is treated with anti-tuberculous agents.
- Antibiotics: Brain abscesses are usually polymicrobial, with the most common bugs being microaerophilic streptococci (viridans) and anaerobic bacteria (bacteroides, anaerobic strep and fusobacterium).
- S. aureus, and enterobacteriacae are also seen.
- Bugs associated with trauma include S. aureus and clostridium sp.
- Empiric Rx usually starts with high-dose PCN (10 – 20 million units / d), metronidazole, +/- a 3rd gen cephalosporin.
- 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.[1]
Antimicrobial Regimen
Brain abscess
- Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.
- Brain abscess in otherwise healthy patients
- Preferred regimen: (Cefotaxime 8–12 g/day IV q4–6h OR Ceftriaxone 4 g/day IV q12h) AND Metronidazole 30 mg/kg/day IV q6h
- Alternative regimen: Meropenem 6 g/day IV q8h
- Brain abscess with comorbidities
- Otitis media, mastoiditis, or sinusitis
- Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h
- Dental infection
- Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h
- Penetrating trauma or post-neurosurgy
- Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h OR Cefepime 2 g IV q12h) AND Vancomycin 30–45 mg/kg/day q8–12h
- Lung abscess, empyema, or bronchiectasis
- Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h AND TMP-SMZ 10–20 mg/kg/day q6–12h
- Bacterial endocarditis
- Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h AND Gentamicin 5 mg/kg/day IV q8h
- Congenital heart disease
- Preferred regimen: Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h
- Transplant recipients
- Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h AND Voriconazole 8 mg/kg/day q12h AND (TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h)
- Patients with HIV/AIDS
- Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd
- Staphylococcus aureus coverage
- Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h
- Mycobacterium tuberculosis coverage
- Preferred regimen: Isoniazid 300 mg qd AND Rifampin 600 mg qd AND Pyrazinamide 15–30 mg qd AND Ethambutol 15 mg/kg/day qd
- Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.
- Bacteria
- Actinomyces
- Preferred regimen: Penicillin G 4 MU IV q4h
- Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h
- Bacteroides fragilis
- Preferred regimen: Metronidazole 30 mg/kg/day IV q6h
- Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h
- Enterobacteriaceae
- Preferred regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h
- Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR TMP-SMZ 10–20 mg/kg/day q6–12h OR Ciprofloxacin 800–1200 mg/day IV q8–12h OR Meropenem 2 g IV q8h
- Fusobacterium
- Preferred regimen: Metronidazole 30 mg/kg/day q6h
- Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h OR Meropenem 2 g IV q8h
- Haemophilus
- Preferred regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h
- Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR TMP-SMZ 10–20 mg/kg/day q6–12h
- Listeria monocytogenes
- Preferred regimen: Ampicillin 12 g/day q4h OR Penicillin G 4 MU IV q4h
- Alternative regimen: TMP-SMZ 10–20 mg/kg/day q6–12h
- Nocardia
- Preferred regimen: TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h
- Alternative regimen: Meropenem 2 g IV q8h OR Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Amikacin 15 mg/kg/day IV q8h
- Prevotella melaninogenica
- Preferred regimen: Metronidazole 30 mg/kg/day q6h
- Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h OR Meropenem 2 g IV q8h
- Pseudomonas aeruginosa
- Preferred regimen: Ceftazidime 6 g/day q8h OR Cefepime 6 g/day q8h
- Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR Ciprofloxacin 800–1200 mg/day IV q8–12h OR Meropenem 2 g IV q8h
- Staphylococcus aureus, methicillin-resistant (MRSA)
- Preferred regimen: Vancomycin 30–45 mg/kg/day 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: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin.
- Staphylococcus aureus, methicillin-susceptible (MSSA)
- Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h
- Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h
- Streptococcus
- Preferred regimen: Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h
- Alternative regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Vancomycin 30–45 mg/kg/day IV q8–12h
- Fungi
- Aspergillus
- Preferred regimen: Voriconazole 8 mg/kg/day q12h
- Alternative regimen: Amphotericin B deoxycholate 0.6–1.0 mg/kg/day IV q24h OR Amphotericin B lipid complex 5 mg/kg/day IV q24h OR Itraconazole 400–600 mg/day IV q12h OR Posaconazole 800 mg/kg/day IV q6–12h
- Candida
- Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
- Alternative regimen: Fluconazole 400–800 mg/day IV q24h
- Cryptococcus neoformans
- Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
- Alternative regimen: Fluconazole 400–800 mg/day IV q24h
- Mucorales
- Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
- Alternative regimen: Posaconazole 800 mg/kg/day IV q6–12h
- Pseudallescheria boydii (Scedosporium apiospermum)
- Preferred regimen: Voriconazole 8 mg/kg/day q12h
- Alternative regimen: Itraconazole 400–600 mg/day IV q12h OR Posaconazole 800 mg/kg/day IV q6–12h
- Protozoa
- Toxoplasma gondii
- Preferred regimen: Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd
- Alternative regimen (1): Pyrimethamine 25–100 mg/day qd AND Clindamycin 2400–4800 mg/day IV q6h
- Alternative regimen (2): Pyrimethamine 25–100 mg/day qd AND (Azithromycin 1200–1500 mg/day IV q24h OR Atovaquone 750 mg IV q6h OR Dapsone 100 mg PO q24h)
- Alternative regimen (3): TMP-SMZ 10–20 mg/kg/day q6–12h
References
- ↑ 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.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
- ↑ 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.