Brain abscess medical therapy

Revision as of 15:11, 28 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.

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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