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]

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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.

Medical Therapy

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.


Brain Abscess Empiric Therapy Adapted from Principles And Practice Of Infectious Disease[1]

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[2]

Click on the following categories to expand treatment regimens.

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

Click on the following categories to expand treatment regimens.

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

  1. 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.
  2. 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.


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