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| {{Subdural empyema}} | | {{Subdural empyema}} |
| {{CMG}}; {{AE}} {{JS}} | | {{CMG}} {{AE}} {{JS}}; {{AG}} |
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| ==Overview== | | ==Overview== |
| [[Subdural empyema]], also referred to as ''subdural abscess'', ''pachymeningitis interna'' and ''circumscript meningitis'', is a life-threatening infection, first reported in literature approximately 100 years ago.<ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref> It consists of a localised collection of [[purulent]] material, usually unilateral, between the [[dura mater]] and the[[arachnoid mater]]. It accounts for about 15-22% of the reported focal intracranial [[infections]]. The empyema may develop intracranially (about 95%) or in the [[spinal canal]] (about 5%), and in both cases, it constitutes a [[Medical emergency|medical]] and [[Surgical emergency|neurosurgical emergency]].<ref name="pmid12521560">{{cite journal| author=Greenlee JE| title=Subdural Empyema. | journal=Curr Treat Options Neurol | year= 2003 | volume= 5 | issue= 1 | pages= 13-22 | pmid=12521560 | doi= |pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12521560 }} </ref> The intracranial type tends to behave like an expanding mass, causing clinical symptoms, such as [[fever]], [[lethargy]], [[headache]] and neurological deficits. These, result from the extrinsic compression of the [[brain]], caused not only from the [[inflammatory]] mass, but also from the [[inflammation]] of the [[brain]] and [[meninges]]. Because the [[subdural space]] has no septations, except in areas where [[arachnoid granulations]] attach to the [[dura mater]], the subdural empyema tends to spread quickly, until it finds those boundaries.
| | Subdural empyema is a medical emergency and requires prompt treatment. 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. The preferred regimen for intracranial subdural empyema includes ([[vancomycin]] 30–45 mg/kg/day IV q8–12h for 3-4 weeks {{or}} [[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. The preferred regimen for spinal subdural empyema includes ([[vancomycin]] 30–45 mg/kg/day IV q8–12h for 3-4 weeks {{or}} [[nafcillin]] 2 g IV q4h for 3-4 weeks {{or}} [[oxacillin]] 2 g IV q4h for 3-4 weeks). Duration of therapy is usually 3-4 weeks, but more prolonged therapy (total of 6-8 weeks) may be necessary among patients who develop complications of the disease, such as osteomyelitis. |
| In children, subdural empyema most often happens as a complication of [[meningitis]], while in adults it usually occurs as a complication of [[sinusitis]], [[otitis media]], [[mastoiditis]], [[trauma]] or as a complication of neurological procedures.<ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref> The most common [[pathogens]] in the intracranial type are [[anaerobic]] and [[microaerophilic]] ''[[streptococci]]'', however others like ''[[Escherichia coli]]'' and ''[[Bacteroides]]'' may be present simultaneously. Spinal subdural empyemas, on the other hand, are almost always caused by''[[streptococci]]'' or by ''[[staphylococcus aureus]]''.<ref name="pmid12521560">{{cite journal| author=Greenlee JE| title=Subdural Empyema. | journal=Curr Treat Options Neurol | year= 2003 | volume= 5 | issue= 1 | pages= 13-22 | pmid=12521560 | doi= | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12521560 }} </ref>
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| The classic clinical syndrome includes acute [[fever]], that rapidly progresses into neurological deterioration, which if left untreated will eventually lead to a [[coma]]and death.<ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref> The diagnostic procedure of choice is the [[MRI]] with [[gadolinium]] enhancement.
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| Since the clinical symptoms might be mild and unspecific initially, the rapid diagnosis and treatment are crucial. The sooner the proper treatment is initiated, the better the recovery will be. The treatment, for almost all causes, requires prompt [[surgical]] drainage and [[antibiotic]] therapy.<ref name="pmid12521560">{{cite journal|author=Greenlee JE| title=Subdural Empyema. | journal=Curr Treat Options Neurol | year= 2003 | volume= 5 | issue= 1 | pages= 13-22 | pmid=12521560 | doi=|pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12521560 }} </ref> With treatment, resolution of the [[empyema]] occurs from the dural side, and, if it is complete, a thickened [[dura mater|dura]] may be the only residual finding.
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| ==Medical Therapy== | | ==Medical Therapy== |
| In the treatment of subdural empyema, an early accurate diagnosis, timely surgical intervention and appropriate [[antibiotic]] therapy, are essential to a favorable outcome, with no, or the least sequelae possible. As a general rule, the treatment of intracranial or spinal subdural empyema requires both prompt surgical drainage and appropriate [[antibiotic]] therapy, an exception being, when there are contraindications to [[surgery]] or significant mortality risks.<ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref> The evacuation of the empyema can be done either by [[craniotomy]] or [[burr hole]] drainage.<ref>{{Cite book | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages = }}</ref> Although the [[pus]] collection might be localised by imaging studies, and a evacuated by placement of a [[burr hole]], the procedure of choice for evacuation of [[subdural]] purulent material is a wide range [[craniotomy]] with irrigation of the area. This improves the outcome by allowing wide exposure and adequate exploration, since the goal of the procedure is not only the evacuation of the [[pus]], but also the eradication of the source of the [[infection]]. <ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref>
| | The treatment of intracranial or spinal subdural empyema requires both prompt surgical drainage and appropriate [[antibiotic]] therapy.<ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref> |
| After surgical drainage, the [[antibiotic]] therapy should be given parenterically for a period of 3-4 weeks however, complications, such as cranial [[osteomyelitis]], may require longer therapy.
| | Some patients may also present with [[seizures]] as a complication to subdural empyema, either during the acute phase or up to 2 years following. In these patients, therapy with [[phenytoin]] may be needed. Depending on the severity of the disease and the degree of neurological sequelae, [[physical therapy|physical]] and [[speech therapy]] may also be recommended.<ref name="pmid12521560">{{cite journal| author=Greenlee JE| title=Subdural Empyema. | journal=Curr Treat Options Neurol | year= 2003 | volume= 5 | issue= 1 | pages= 13-22 | pmid=12521560 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12521560 }} </ref> |
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| ===Intracranial subdural empyema=== | | ==Antimicrobial Regimen== |
| This subtype may have multiple [[pathogens]] involved, therefore initial [[antibiotic]] therapy should cover ''[[Staphylococcus aureus]]'', [[microaerophilic]] and [[anaerobic]] [[streptococci]] and gram negative organisms. <ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref>
| | {{ID-Subdural empyema}} |
| *Antibiotics for community-acquired subdural empyema should include a combination of:
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| #[[Nafcillin]], [[Oxacillin]] or [[Vancomycin]]
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| #Third generation [[Cephalosporin]]
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| #[[Metronidazole]]
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| *Patients with hospital-acquired subdural empyema may be infected with different pathogens, such as [[Pseudomonas]] spp. or [[MRSA]]. Therefore, should receive coverage with the following:
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| #[[Carbapenem]]
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| #[[Vancomycin]]
| | [[Category:Infectious Disease Project]] |
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| #([[Metronidazole]] is not necessary for the therapy of anaerobic agents in the presence of [[Meropenem]])
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| ===Spinal subdural empyema===
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| Initial [[antibiotic]] therapy should be directed to ''[[Staphylococcus aureus]]'' and ''[[Streptococci]]'' and should include:
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| #[[Nafcillin]], [[Oxacillin]] or [[Vancomycin]]
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| The definitive pathogen diagnosis is made by [[Gram's stain]] and culture of the fluid obtained from the surgical drainage. After this diagnosis has been made, a more pathogen-oriented antibiotic therapy can be given.
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| ==Antibiotic Therapy==
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| *Empirical antibiotic therapy of focal CNS Infections: <ref>{{Cite book | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6| pages = }}</ref>
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| <SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
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| <div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 400px; background: #A1BCDD; text-align: center;">
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| <font color="#FFF">
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| '''INDICATION'''
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| <div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 400px; background: #4479BA;">
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| <font color="#FFF">
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| ▸ '''''Infants < 1 month'''''
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| </font>
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| </div>
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| <div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 400px; background: #4479BA;">
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| ▸ '''''Infants 1-3 months'''''
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| </font>
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| </div>
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| <div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 400px; background: #4479BA;">
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| <font color="#FFF">
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| ▸ '''''> 3 months Immunocompetent Children; Adults < 55 years'''''
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| </font>
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| </div>
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| <div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 400px; background: #4479BA;">
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| <font color="#FFF">
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| ▸ '''''Adults > 55 years; Alcoholics; Debilitating Illness'''''
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| </font>
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| </div>
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| <div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 400px; background: #4479BA;">
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| <font color="#FFF">
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| ▸ '''''Specific Situations'''''
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| </font>
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| </div>
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| ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Infants < 1 month}}
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ampicillin]] Child: 200 mg/kg/day IV, q4h; Adult: 12g/day IV, q4h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] Child: 200 mg/kg/day IV, q6h; Adult: 12 g/day IV, q4h'''''
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| {| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
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| {| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
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| ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Infants 1-3 months}}
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| |-
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
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| |-
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ampicillin]] Child: 200 mg/kg/day IV, q4h; Adult: 12 g/day IV, q4h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| |-
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] Child: 200 mg/kg/day IV, q6h; Adult: 12 g/day IV, q4h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ceftriaxone]] Child: 100 mg/kg/day IV, q12h; Adult: 4 g/day IV, q12h'''''
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| {| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
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| ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|> 3 months Immunocompetent Children; Adults < 55 years}}
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]] Child: 60 mg/kg/day IV, q6h; Adult: 2 g/day IV, q12h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] Child: 200 mg/kg/day IV, q6h; Adult: 12 g/day IV, q4h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ceftriaxone]] Child: 100 mg/kg/day IV, q12h; Adult: 4 g/day IV, q12h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefepime]] Child: 150 mg/kg/day IV, q8h; Adult: 6 g/day IV, q8h'''''
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| {| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
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| {| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
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| ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Adults > 55 years; Alcoholics; Debilitating Illness}}
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ampicillin]] Child: 200 mg/kg/day IV, q4h; Adult: 12 g/day IV, q4h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vacomycin]] Child: 60 mg/kg/day IV, q6h; Adult: 2 g/day IV, q12h'''''
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| |-
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] Child: 200 mg/kg/day IV, q6h; Adult: 12 g/day IV, q4h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ceftriaxone]] Child: 100 mg/kg/day IV, q12h; Adult: 4 g/day IV, q12h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefepime]] Child: 150 mg/kg/day IV, q8h; Adult: 6 g/day IV, q8h'''''
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| ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Specific Situations<sup>†</sup>}}
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ampicillin]] Child: 200 mg/kg/day IV, q4h; Adult: 12 g/day IV, q4h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vacomycin]] Child: 60 mg/kg/day IV, q6h; Adult: 2 g/day IV, q12h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ceftazidime]] Child: 150 mg/kg/day IV, q8h; Adult: 6 g/day IV, q8h'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] Child: 120 mg/kg/day IV, q8h; Adult: 3 g/day IV, q8h'''''
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | <SMALL><sup>†</sup> Hospital Acquired Meningitis; Posttraumatic Meningitis; Postneurosurgery Meningitis; Neutropenia; Impaired Cell-mediated Immunity</SMALL>
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| ==Subdural Empyema Drug Summary==
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| ===Nafcillin and Oxacillin===
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| *Group of narrow spectrum antibiotics, of the penicillin class, both penicillinase-resistant. Their mechanism of action is based on binding transpeptidases, thereby blocking the cross-linkage of peptidoglycan. They are also involved in the activation of autolytic enzymes.
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| *They are used to treat gram-positive bacteria, particularly ''staphylococci'', however are not indicated in the treatment of [[MRSA]]/[[ORSA]].
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| *They are known to cause [[hypersensitivity]] reactions and to interfere with [[cytochrome P-450]]. Their use in [[congestive heart failure]] and [[kidney disease]] patients should also be cautious because of risk of [[edema]].
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| ===Vancomycin===
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| *A [[glycopeptide antibiotic]] that exerts its activity by inhibiting [[peptidoglycan]] synthesis and hence bacterial cell walls. It has [[bactericidal]] activity agains most pathogens and [[bacteriostatic]] activity agains [[enterococci]].
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| *A narrow spectrum [[antibiotic]] used only for [[gram-positive bacteria]].
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| *Due to its toxicity ([[Ototoxicity]], [[Nephrotoxicity]] and [[Thrombophlebitis]]), its use is restricted to multidrug-resistant organisms ([[MRSA]]/[[ORSA]], ''[[Clostridium difficile]]'').
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| *In recent years, the emergence of vancomycin-resistant pathogens, has increased the use of [[antibiotics]], such as [[carbapenem]] and [[linezolid]].
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| ===Cephalosporin===
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| *A bactericidal [[antibiotic]], with a similar mechanism of action as other [[penicillins]], [[cephalosporins]] interfere with the synthesis of [[peptidoglycan]] of the [[cell wall]], being however less susceptible to penicillinases.
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| *Used for prophylaxis and treatment of certain [[bacteria]].
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| *There are 4 generations of [[cephalosporins]]: 1st generation are indicated for [[gram-positive bacteria]], while 2nd, 3rd and 4th generations have increased activity against [[Gram-negative|gram negative]] organisms.
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| *1st generation [[cephalosporins]] include: [[cefalexin]] and [[cefazolin]]; 2nd generation: [[cefuroxime]] and [[cefoxitin]]; 3rd generation: [[ceftriaxone]] and [[cefotaxime]]; and 4th generation: [[cefepime]] and [[cefquinome]].
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| *Organisms not usually covered by [[cephalosporins]] include: ''[[Listeria]]'', [[MRSA]] and [[Enterococci]].
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| *Possible adverse effects include: [[nausea]], [[diarrhea]], [[rash]], [[hypersensitivity]] reactions, [[vitamin K]] deficiency and increased [[nephrotoxicity]] of [[aminoglycosides]], when given concomitantly.
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| ===Metronidazole===
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| *A [[nitroimidazole]] [[antibiotic]], [[bactericidal]] against anaerobic organisms, with [[antiprotozoal]] activity. It acts by forming free radical metabolites within the bacterial cell, which damages the bacterial [[DNA]]. When given with [[clarithromycin]] and a [[proton pun inhibitor]], is used in the treatment of [[''Helicobacter pylori'']].
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| *Used in the treatment of organisms such as: ''[[Clostridium difficile]]'', ''[[Entamoeba]]'', ''[[Trichomonas]]'', ''[[Giardia]]'' and ''[[Gardnerella vaginalis]]''.
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| *Possible adverse effects include: [[nausea]], [[diarrhea]], [[headaches]], being associated with [[thrombophlebitis]], when administered intravenously.
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| ===Carbapenem===
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| *Broad spectrum [[beta-lactam]] [[antibiotic]], with a structure which protects it from the action of [[beta-lactamases]]. Active against [[gram-positive]] [[cocci]], [[gram-negative]] [[rods]] and [[anaerobic]] [[bacteria]], with the exception of [[intracellular]] organisms. Administered intravenously.
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| *Examples of [[carbapenems]] include [[imipenem]], [[meropenem]] and [[ertapenem]].
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| *The significant side-effects including [[gastrointestinal]] problems, [[rash]] and [[CNS]] toxicity limit its use.
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| ==Other Therapies==
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| 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]] might be needed.
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| ===Phenytoin===
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| *Commonly know as [[Dilantin]], it is used to treat partial [[seizures]] or generalised [[tonic-clonic seizures]].
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| *Its effect is believed to be due to the voltage-dependent blockage of [[voltage-gated sodium channels]]. [[Phenytoin]] is then able to selectively inhibit pathological hyperexcitability in epilepsy, without affecting ongoing activity. It also has the ability of blocking persistent sodium current, which is of great use in seizure control.
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| *It has adverse effects,such as: [[nystagmus]], [[cerebellum]] atrophy when administered at chronically high levels, [[megaloblastic anemia]], [[teratogenicity]], [[gingival hyperplasia]], [[hypertrichosis]] and [[rash]].
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| ==References==
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| {{Reflist|2}}
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| [[Category:Infectious disease]] | |
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| {{WH}}
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| {{WS}}
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