Epidural abscess medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Epidural abscess is a rare [[suppurative]] [[infection]] resulting in [[pus]] loculation in the [[cranial cavity]] or the [[spinal canal]]. Treatment of epidural abscess generally involves a combined medical and surgical approach | Epidural abscess is a rare [[suppurative]] [[infection]] resulting in [[pus]] loculation in the [[cranial cavity]] or the [[spinal canal]]. Treatment of epidural abscess generally involves a combined medical and surgical approach. For cranial epidural abscess, the choice of antibiotics should be based on the host factors and the Gram-stain results of the drained abscess. [[Vancomycin]] should be added to the empiric regimen if ''[[Staphylococcus aureus]]'' is suspected. [[Linezolid]] may be considered in epidural abscess caused by [[Gram-positive cocci]] unresponsive to conventional treatment. [[Metronidazole]] is recommended for anaerobic infections. Broad spectrum antibiotics (such as [[cefepime]], [[ceftazidime]], or [[meropenem]]) should be administered to treat aerobic [[Gram-negative bacilli]]. Empirical antimicrobial therapy for spinal epidural abscess should cover Staphylococcus ([[vancomycin]] pending susceptibility testing) and aerobic [[Gram-negative bacilli]] ([[cefepime]], [[ceftazidime]], or [[meropenem]]). Regimen should be adjusted as culture results and susceptibility testing permit. Antimicrobial therapy is usually continued for 4 to 6 weeks after surgical drainage or for 6 to 8 weeks if osteomyelitis is present. Patients with tuberculous epidural abscess must receive a 12-month course of antituberculous therapy. | ||
==Medical Therapy== | ==Medical Therapy== | ||
Revision as of 19:21, 27 April 2015
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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]
Overview
Epidural abscess is a rare suppurative infection resulting in pus loculation in the cranial cavity or the spinal canal. Treatment of epidural abscess generally involves a combined medical and surgical approach. For cranial epidural abscess, the choice of antibiotics should be based on the host factors and the Gram-stain results of the drained abscess. Vancomycin should be added to the empiric regimen if Staphylococcus aureus is suspected. Linezolid may be considered in epidural abscess caused by Gram-positive cocci unresponsive to conventional treatment. Metronidazole is recommended for anaerobic infections. Broad spectrum antibiotics (such as cefepime, ceftazidime, or meropenem) should be administered to treat aerobic Gram-negative bacilli. Empirical antimicrobial therapy for spinal epidural abscess should cover Staphylococcus (vancomycin pending susceptibility testing) and aerobic Gram-negative bacilli (cefepime, ceftazidime, or meropenem). Regimen should be adjusted as culture results and susceptibility testing permit. Antimicrobial therapy is usually continued for 4 to 6 weeks after surgical drainage or for 6 to 8 weeks if osteomyelitis is present. Patients with tuberculous epidural abscess must receive a 12-month course of antituberculous therapy.
Medical Therapy
Several studies have reached the conclusion that the best approach to therapy of epidural abscess, either intracranial or spinal, is a combination of surgical drainage along with 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, decompressive laminectomy and debridement of infected tissues, in the case of SEA, and burr hole placement or craniotomy, in the case of IEA, should take place as early as possible. [2][3] 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 unlikely reversible, due to being present for more than 24 to 36 hours. Sometimes, in these situations emergency laminectomy is still performed, not to restore the lost function, but to treat the abscess and prevent a sepsis episode
- panspinal infection, therefore the laminectomy would be impracticable. In this case, the physician might consider a limited laminectomy or laminotomy with catheter insertion at the top and bottom of the spinal canal, for drainage and irrigation.
There are several reported cases in which patients recovered from epidural abscess, without surgical treatment, following simple diagnostic aspiration with antibiotic therapy. In these patients however, there was no neurologic deficit related to the abscess or it was simply accompanied by minor weakness at initial presentation. [4] Besides the antibiotic therapy, this conservative approach also includes:
- close neurologic monitoring strategy, defined before treatment initiation
- follow-up MRI to evaluate the status of the abscess and confirm its resolution
- immediate surgery, in case of neurologic deterioration.
The indication for a specific antibiotic should be given 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 ESR, CRP, pain and function, along with resolution of 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 after surgery, or longer in case of osteomyelitis. [5] This should cover: [2]
This regimen must include: [6][1]
- Penicillin with anti-staphylococcal activity or Vancomycin in case of suspicion of MRSA
- Third-generation cephalosporin
- This regimen might also include Metronidazole
Spinal Epidural Abscess
Initial antibiotic therapy for this type of abscess should target staphylococci and aerobic gram negative bacilli, particularly in patients with history of IV drug use or spinal procedures. The treatment should last for a period of 4 to 6 weeks, or longer, up to 8 weeks, in case there is contiguous osteomyelitis. [7] Therefore, the antibiotic regimens for the unknown organism of intracranial epidural abscess may also be applied to the spinal epidural abscess.
Antibiotic Therapy
- Empiric antibiotic therapy of focal CNS Infections:[8]
▸ Click on the following categories to expand treatment regimens.
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Age and Predisposing Factors ▸ Infants < 1 month ▸ Infants 1-3 months ▸ > 3 months Immunocompetent Children; Adults < 55 years ▸ Adults > 55 years; Alcoholics; Debilitating Illness ▸ Specific Situations |
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When the responsible organism has been isolated and identified in cultures, the therapy should be re-directed to this agent. [9]
- Pathogen-based antibiotic therapy of focal CNS Infections: [10]
▸ Click on the following categories to expand treatment regimens.
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Pathogen-Based Therapy ▸ Neisseria meningitidis ▸ Streptococcus pneumoniae ▸ Gram negative bacilli ▸ Pseudomonas aeruginosa ▸ Staphylococci ▸ Listeria monocytogenes ▸ Haemophilus influenzae ▸ Streptococcus agalactiae ▸ Bacteroides fragilis ▸ Fusobacterium spp. |
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Epidural Abscess Drug Summary
Nafcillin and Oxacillin
- Group of narrow spectrum antibiotics, of the penicillin class, both penicillinase-resistant. Their mechanism of action is based on binding transpeptidases, thereby blocking the cross-linkage of peptidoglycan. They are also involved in the activation of autolytic enzymes.
- They are used to treat gram-positive bacteria, particularly staphylococci, however are not indicated in the treatment of MRSA/ORSA.
- They are known to cause hypersensitivity reactions and to interfere with cytochrome P-450. Their use in congestive heart failure and kidney disease patients should also be cautious because of risk of edema.
- The dosage may need to be adjusted in patients suffering from kidney or liver disease.[11]
Vancomycin
- A glycopeptide antibiotic that exerts its activity by inhibiting peptidoglycan synthesis and hence bacterial cell walls. It has bactericidal activity agains most pathogens and bacteriostatic activity agains enterococci.
- A narrow spectrum antibiotic used only for gram-positive bacteria.
- Due to its toxicity (Ototoxicity, Nephrotoxicity and Thrombophlebitis), along with risk of anaphylaxis, Stevens-Johnson syndrome, neutropenia and thrombocytopenia[11], its use is restricted to multidrug-resistant organisms (MRSA/ORSA, Clostridium difficile).
- In recent years, the emergence of vancomycin-resistant pathogens, has increased the use of antibiotics, such as carbapenem and linezolid.
Cephalosporin
- A bactericidal antibiotic, with a similar mechanism of action as other penicillins, cephalosporins interfere with the synthesis of peptidoglycan of the cell wall, being however less susceptible to penicillinases.
- Used for prophylaxis and treatment of certain bacteria.
- There are 4 generations of cephalosporins: 1st generation are indicated for gram-positive bacteria, while 2nd, 3rd and 4th generations have increased activity against gram negative organisms.
- 1st generation cephalosporins include: cefalexin and cefazolin; 2nd generation: cefuroxime and cefoxitin; 3rd generation: ceftriaxone and cefotaxime; and 4th generation: cefepime and cefquinome.
- Organisms not usually covered by cephalosporins include: Listeria, MRSA and Enterococci.
- Possible adverse effects include: nausea, diarrhea, rash, hypersensitivity reactions, vitamin K deficiency and increased nephrotoxicity of aminoglycosides, when given concomitantly.
Metronidazole
- A nitroimidazole antibiotic, bactericidal against anaerobic organisms, with antiprotozoal activity. It acts by forming free radical metabolites within the bacterial cell, which damages the bacterial DNA. When given with clarithromycin and a proton pump inhibitor, is used in the treatment of ''Helicobacter pylori''.
- Used in the treatment of organisms such as: Clostridium difficile, Entamoeba, Trichomonas, Giardia and Gardnerella vaginalis.
- Possible adverse effects include: nausea, diarrhea, headaches, encephalopathy, cerebellar ataxia, neutropenia[11] and association with thrombophlebitis, when administered intravenously.
- Its use may cause darker red urine.
Carbapenem
- Broad spectrum beta-lactam antibiotic, with a structure which protects it from the action of beta-lactamases. Active against gram-positive cocci, gram-negative rods and anaerobic bacteria, with the exception of intracellular organisms. Administered intravenously.
- Examples of carbapenems include imipenem, meropenem and ertapenem.
- The significant side-effects including gastrointestinal problems, rash and CNS toxicity limit its use.
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.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ 11.0 11.1 11.2 Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.