Sandbox brain abscess

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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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.

Treatment

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.

Brain Abscess Empiric Therapy Adapted from Principles And Practice Of Infectious Disease

Bacteira Brain Abscess

Click on the following categories to expand treatment regimens.

Empiric Therapy   ▸  Otitis media or mastoiditis   ▸  Sinusitis   ▸  Dental infection   ▸  Penetrating trauma   ▸  Postsurgical   ▸  Pulmonary resource   ▸  Bacterial endocarditis   ▸  Congenital heart disease   ▸  Unknown

Otitis media or mastoiditis Preferred Regimen ▸ Metronidazole 500 mg/kg q8h PLUS ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸Ceftriaxone 2 g IV q12h Sinusitis Preferred Regimen ▸ Metronidazole 500 mg/kg q8h PLUS ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸Ceftriaxone 2 g IV q12h† Dental infection Preferred Regimen ▸ Penicillin 4 million U IV q4h PLUS ▸ Metronidazole 500 mg/kg q8h Penetrating trauma Preferred Regimen‡ ▸ Vancomycin 30-45 mg/kg IV q8-12h PLUS ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸Ceftriaxone 2 g IV q12h Postsurgical Preferred Regimen‡ ▸ Vancomycin 30-45 mg/kg IV q8-12h PLUS ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸Ceftriaxone 2 g IV q12h Lung abscess, empyema, bronchiectasis Preferred Regimen ▸ Penicillin 4 million U IV q4h PLUS ▸ Metronidazole 500 mg q8h PLUS ▸ Sulfonamide 500 mg q8h§ Bacterial endocarditis Preferred Regimen# ▸ Vancomycin 30-45 mg/kg IV q8-12h PLUS ▸ Gentamicin 1.7 mg/kg IV q8h Congenital heart disease Preferred Regimen ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸Ceftriaxone 2 g IV q12h Unknown Preferred Regimen ▸ Vancomycin 30-45 mg/kg IV q8-12h PLUS ▸ Metronidazole 500 mg q8h PLUS ▸ Cefotaxime 8-12 g/day IV q4-6h OR ▸Ceftriaxone 2 g IV q12h‡

†:Add vancomycin when infection caused by methicillin-resistant Staphylococcus aureus is suspected. ‡:Use ceftazidime or cefepime as the cephalosporin if Pseudomonas aeruginosa is suspected. §:Trimethoprim-sulfamethoxazole; include if a Nocardia spp. is suspected.

Brain Absecss Special Pathogen Therapy Adapted from Principles And Practice Of Infectious Disease

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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(monitor peak and trough serum concentrations) 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

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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 5 mg/kg PO qd OR ▸ Itraconazole 400 mg IV q12h¶ OR ▸ Posaconazole 200-400 mg q6-12h¶ Candida spp. Preferred Regimen ▸ Amphotericin B deoxycholate 0.6-1.0 mg/kg IV qd♠ OR ▸ Liposomal amphotericin B 5 mg/kg IV qd OR ▸ Amphotericin B lipid complex 5 mg/kg PO qd PLUS ▸ Flucytosine 25 mg/kg PO q6h Alternative Regimen ▸ Fluconazole 400-800 mg IV qd Cryptococcus neoformans ▸Amphotericin B deoxycholate 0.6-1.0 mg/kg IV qd♠ OR ▸ Liposomal amphotericin B 5 mg/kg IV qd OR ▸ Amphotericin B lipid complex 5 mg/kg PO qd PLUS ▸Flucytosine 25 mg/kg PO q6h Alternative Regimen ▸Fluconazole 400-800 mg IV qd Mucorales Preferred Regimen ▸Amphotericin B deoxycholate 0.6-1.0 mg/kg IV qd♠ OR ▸ Liposomal amphotericin B 5 mg/kg IV qd OR ▸ Amphotericin B lipid complex 5 mg/kg PO qd 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

Protozoa Brain Abscess

Toxoplasma gondii Preferred Regimen ▸ Pyrimethamine 25-75 mg PO qd PLUS ▸ Sulfadiazine 1-1.5 g PO q6h Alternative Regimen ▸ Pyrimethamine 25-75 mg PO qd PLUS ▸ Clindamycin 25-75 mg IV qd OR ▸ Trimethoprim-Sulfamethoxazole 10-20 mg/kg PO q6-12h OR ▸ Pyrimethamine 25-75 mg PO qd PLUS ▸ Azithromycin 1200-1500 mg IV qd OR ▸ Clarithromycin OR ▸ Atovaquone 750 mg PO 6h OR ▸ Dapsone 100 mg PO qd

†:Addition of an aminoglycoside should be considered. ¶:Consider for use in salvage therapy in nonresponding patients or in patients intolerant of amphotericin B–based therapies.

♠:Dosages up to 1.5 mg/kg/day may be used for aspergillosis or mucormycosis. *:Adjust dosage based on trough serum concentration.

References

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