Brain abscess medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sheng Shi, M.D. [2]

Overview

The treatment of brain abscess includes prompt administration of antimicrobial therapy upon suspicion and occasionally drainage to reduce the mass effect. Empiric antimicrobial therapy among otherwise healthy individuals includes metronidazole and either cefotaxime or ceftriaxone. Patients with co-morbidities may require alternative antimicrobial therapies. Administration of steroid therapy is generally not recommended and is only indicated among patients who have brain abscesses with mass effect.

Medical Therapy

Prompt administration of antimicrobial therapy is indicated among all patients with brain abscesses.
Neurosurgery should always be consulted upon diagnosis. The decision of whether to surgically drain, aspirate, or simply administer antimicrobial therapy depends on the number of abscesses, their size, and their location. To learn more about indications of surgical vs. aspiration drainage, click here.
Stereotactic needle biopsy can be performed to obtain tissues for cultures.
A follow-up head CT scan or MRI is usually indicated at 2-4 weeks of follow-up. The improvement on imaging is often delayed compared to clinical improvement.

Antimicrobial Regimen

1. Empiric antimicrobial therapy^[1]^[2]

Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.

1.1 Brain abscess in otherwise healthy patients

Preferred regimen (1): (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 (1): Meropenem 6 g/day IV q8h

1.2 Brain abscess with comorbidities

1.2.1 Otitis media, mastoiditis, or sinusitis

Preferred regimen (1): (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h

1.2.2 Dental infection

Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h

1.2.3 Penetrating trauma or post-neurosurgy

Preferred regimen (1): (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

1.2.4 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

1.2.5 Bacterial endocarditis

Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h AND Gentamicin 5 mg/kg/day IV q8h

1.2.6 Congenital heart disease

Preferred regimen (1): Cefotaxime 8–12 g/day q4–6h
Preferred regimen (2): Ceftriaxone 4 g/day q12h

1.2.7 Transplant recipients

Preferred regimen (1): (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)

1.2.8 Patients with HIV/AIDS

Preferred regimen (1): (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

1.2.9 Staphylococcus aureus coverage

Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h

1.2.10 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

2. Pathogen-directed antimicrobial therapy^[3]^[4]^[5]

Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.

2.1 Bacteria

2.1.1 Actinomyces

Preferred regimen: Penicillin G 4 MU IV q4h
Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h

2.1.2 Bacteroides fragilis

Preferred regimen: Metronidazole 30 mg/kg/day IV q6h
Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h

2.1.3 Enterobacteriaceae

Preferred regimen (1): Cefotaxime 2 g IV q4-6h
Preferred regimen (2): Ceftriaxone 2 g IV q12h
Preferred regimen (3): Cefepime 2 g IV q12h
Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
Alternative regimen (2): TMP-SMZ 10–20 mg/kg/day q6–12h
Alternative regimen (3): Ciprofloxacin 800–1200 mg/day IV q8–12h
Alternative regimen (4): Meropenem 2 g IV q8h

2.1.4 Fusobacterium

Preferred regimen: Metronidazole 30 mg/kg/day q6h
Alternative regimen (1): Clindamycin 2400–4800 mg/day IV q6h
Alternative regimen (2): Meropenem 2 g IV q8h

2.1.5 Haemophilus

Preferred regimen (1): Cefotaxime 2 g IV q4-6h
Preferred regimen (2): Ceftriaxone 2 g IV q12h
Preferred regimen (3): Cefepime 2 g IV q12h
Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
Alternative regimen (2): TMP-SMZ 10–20 mg/kg/day q6–12h

2.1.6 Listeria monocytogenes

Preferred regimen (1): Ampicillin 12 g/day q4h
Preferred regimen (2): Penicillin G 4 MU IV q4h
Alternative regimen (1): TMP-SMZ 10–20 mg/kg/day q6–12h

2.1.7 Nocardia

Preferred regimen (1): TMP-SMZ 10–20 mg/kg/day q6–12h
Preferred regimen (2): Sulfadiazine 4–6 g/day q6h
Alternative regimen (1): Meropenem 2 g IV q8h
Alternative regimen (2): Cefotaxime 2 g IV q4-6h
Alternative regimen (3): Ceftriaxone 2 g IV q12h
Alternative regimen (4): Amikacin 15 mg/kg/day IV q8h

2.1.8 Prevotella melaninogenica

Preferred regimen (1): Metronidazole 30 mg/kg/day q6h
Alternative regimen (1): Clindamycin 2400–4800 mg/day IV q6h
Alternative regimen (2): Meropenem 2 g IV q8h

2.1.9 Pseudomonas aeruginosa

Preferred regimen (1): Ceftazidime 6 g/day q8h
Preferred regimen (2): Cefepime 6 g/day q8h
Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
Alternative regimen (2): Ciprofloxacin 800–1200 mg/day IV q8–12h
Alternative regimen (3): Meropenem 2 g IV q8h

2.1.10 Staphylococcus aureus, methicillin-resistant (MRSA)

Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 4–6 weeks
Alternative regimen (2):TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
Pediatric dose (1): Vancomycin 15 mg/kg/dose IV q6h
Pediatric dose (2): Linezolid 10 mg/kg/dose PO/IV q8h
Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin.

2.1.11 Staphylococcus aureus, methicillin-susceptible (MSSA)

Preferred regimen (1): Nafcillin 2 g IV q4h
Preferred regimen (2): Oxacillin 2 g IV q4h
Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h

2.1.12 Streptococcus

Preferred regimen (1): Penicillin G 4 MU IV q4h
Preferred regimen (2): Ampicillin 2 g IV q4h
Alternative regimen (1): Cefotaxime 2 g IV q4-6h
Alternative regimen (2): Ceftriaxone 2 g IV q12h
Alternative regimen (3): Vancomycin 30–45 mg/kg/day IV q8–12h

2.2 Fungi

2.2.1 Aspergillus

Preferred regimen: Voriconazole 8 mg/kg/day q12h
Alternative regimen (1): Amphotericin B deoxycholate 0.6–1.0 mg/kg/day IV q24h
Alternative regimen (2): Amphotericin B lipid complex 5 mg/kg/day IV q24h
Alternative regimen (3): Itraconazole 400–600 mg/day IV q12h
Alternative regimen (4): Posaconazole 800 mg/kg/day IV q6–12h

2.2.2 Candida

Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
Alternative regimen: Fluconazole 400–800 mg/day IV q24h

2.2.3 Cryptococcus neoformans

Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
Alternative regimen: Fluconazole 400–800 mg/day IV q24h

2.2.4 Mucorales

Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
Alternative regimen: Posaconazole 800 mg/kg/day IV q6–12h

2.2.5 Pseudallescheria boydii (Scedosporium apiospermum)

Preferred regimen: Voriconazole 8 mg/kg/day q12h
Alternative regimen (1): Itraconazole 400–600 mg/day IV q12h
Alternative regimen (2):Posaconazole 800 mg/kg/day IV q6–12h

2.3 Protozoa

2.3.1 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
Alternative regimen (3): Atovaquone 750 mg IV q6h
Alternative regimen (4): Dapsone 100 mg PO q24h
Alternative regimen (4): TMP-SMZ 10–20 mg/kg/day q6–12h

Other Pharmacologic Agents

Steroids

Administration of glucocorticoids is generally not recommended. However, glucorticoids are only indicated when the brain abscess has a mass effect, as suggested by findings on imaging.
Steroid regimen:

Preferred regimen: Dexamethasone 10 mg IV loading dose THEN 4 mg q6h until the mass effect is no longer observed on imaging.

References

↑ 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.

[1] Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.

[2] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[3] Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.

[4] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[5] 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.

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