Subdural empyema medical therapy
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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
Subdural empyema is a medical emergency. Treatment of subdural empyema requires a combined medical and surgical approach. Empiric antimicrobial therapy depends on the location of the infection (intracranial vs. spinal) and whether it was community-acquired or hospital-acquired.
Medical Therapy
- The treatment of intracranial or spinal subdural empyema requires both prompt surgical drainage and appropriate antibiotic therapy[1]
Antimicrobial Regimen
- Empiric antimicrobial therapy
- Metronidazole is recommended if anaerobes are suspected. Metronidazole is not necessary for antianaerobic activity if Meropenem is used.
- For coverage of aerobic Gram-negative bacilli, empiric therapy with Cefepime, Ceftazidime, or Meropenem is appropriate.
- Depending on the clinical response, parenteral antimicrobial therapy should be administered for 3 to 4 weeks after drainage. Parenteral or oral therapy is frequently continued for up to a total of 6 weeks of therapy.
- A longer course of treatment (minimum of 6–8 weeks) may be required if the patient has accompanying osteomyelitis.
- Consider adjunctive medications including prophylactic anticonvulsants, corticosteroids, and mannitol if clinically indicated.
- Intracranial subdural empyema with unclear source of infection
- Preferred regimen: (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks
- Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.
- Intracranial subdural empyema associated with sinusitis or otitis media
- Preferred regimen: (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks
- Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.
- Intracranial subdural empyema after cranial trauma
- Preferred regimen: Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks
- Note: Vancomycin should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.
- Intracranial subdural empyema after neurosurgical procedures
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 3-4 weeks AND Ceftazidime 2 g IV q8h for 3-4 weeks
- Intracranial subdural empyema in neonates (usually associated with meningitis)
- Infants < 1 month
- Preferred regimen: Ampicillin 200 mg/kg/day IV q4h for 3-4 weeks AND Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeks
- Infants 1–3 months
- Preferred regimen: Ampicillin 200 mg/kg/day IV q4h for 3-4 weeks AND (Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeks OR Ceftriaxone 100 mg/kg/day IV q12h for 3-4 weeks)
- Infants > 3 months
- Preferred regimen: Vancomycin 60 mg/kg/day IV q6h for 3-4 weeks AND (Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeksOR Ceftriaxone 100 mg/kg/day IV q12h for 3-4 weeks OR Cefepime 150 mg/kg/day IV q8h for 3-4 weeks)
- Spinal subdural empyema
- Preferred regimen: Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks
- Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.
- Pathogen-directed antimicrobial therapy
- Staphylococcus aureus, methicillin-resistant (MRSA)[4]
- 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 therapy.
References
- ↑ Agrawal, Amit; Timothy, Jake; Pandit, Lekha; Shetty, Lathika; Shetty, J.P. (2007). "A Review of Subdural Empyema and Its Management". Infectious Diseases in Clinical Practice. 15 (3): 149–153. doi:10.1097/01.idc.0000269905.67284.c7. ISSN 1056-9103.
- ↑ Osborn, Melissa K.; Steinberg, James P. (2007-01). "Subdural empyema and other suppurative complications of paranasal sinusitis". The Lancet. Infectious Diseases. 7 (1): 62–67. doi:10.1016/S1473-3099(06)70688-0. ISSN 1473-3099. PMID 17182345. Check date values in:
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(help) - ↑ Greenlee, John E. (2003-01). "Subdural Empyema". Current Treatment Options in Neurology. 5 (1): 13–22. ISSN 1092-8480. PMID 12521560. Check date values in:
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(help) - ↑ 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.
Other Pharmacologic Therapies
- Some patients might present with seizures, either during the acute phase of the subdural empyema, or up to 2 years thereafter. In these patients, therapy with phenytoin may be needed.
- Depending on the severity of the disease and the degree of neurological sequelae, physical and/or speech therapy might also be required.[1]
References
- ↑ Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.