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* Septic thrombosis of cavernous or dural venous sinus
*Cavernous sinus thrombosis is considered a medical emergency.
:* '''Empiric antimicrobial therapy'''<ref>{{Cite journal| doi = 10.1161/STR.0b013e31820a8364| issn = 1524-4628| volume = 42| issue = 4| pages = 1158–1192| last1 = Saposnik| first1 = Gustavo| last2 = Barinagarrementeria| first2 = Fernando| last3 = Brown| first3 = Robert D.| last4 = Bushnell| first4 = Cheryl D.| last5 = Cucchiara| first5 = Brett| last6 = Cushman| first6 = Mary| last7 = deVeber| first7 = Gabrielle| last8 = Ferro| first8 = Jose M.| last9 = Tsai| first9 = Fong Y.| last10 = American Heart Association Stroke Council and the Council on Epidemiology and Prevention| title = Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association| journal = Stroke; a Journal of Cerebral Circulation| date = 2011-04| pmid = 21293023}}</ref><ref>{{Cite journal| issn = 0003-9926| volume = 161| issue = 22| pages = 2671–2676| last1 = Ebright| first1 = J. R.| last2 = Pace| first2 = M. T.| last3 = Niazi| first3 = A. F.| title = Septic thrombosis of the cavernous sinuses| journal = Archives of Internal Medicine| date = 2001-12-10| pmid = 11732931}}</ref><ref>{{Cite journal| issn = 0022-2151| volume = 107| issue = 9| pages = 803–808| last = Singh| first = B.| title = The management of lateral sinus thrombosis| journal = The Journal of Laryngology and Otology| date = 1993-09| pmid = 8228594}}</ref><ref>{{Cite journal| issn = 0025-7974| volume = 65| issue = 2| pages = 82–106| last1 = Southwick| first1 = F. S.| last2 = Richardson| first2 = E. P.| last3 = Swartz| first3 = M. N.| title = Septic thrombosis of the dural venous sinuses| journal = Medicine| date = 1986-03| pmid = 3512953}}</ref>
*Duration of therapy is usually a total of 3-4 weeks. More prolonged administration of antimicrobial therapy (total of 6-8 weeks) may be indicated among patients who are suspected to have developed complications (e.g. suppurative intracranial disease).
::* Preferred regimen: ([[Nafcillin]] 2 g IV q4h or [[Oxacillin]] 2 g IV q4h) {{and}} ([[Ceftriaxone]] 2 g IV q12h or [[Cefotaxime]] 8–12 g/day IV q4–6h) {{and}} [[Metronidazole]] 7.5 mg/kg IV q6h
*ENT surgery must be consulted to evaluate the need of surgical drainage (e.g. sphenoidotomy if sphenoid sinus infection is the primary cause).
::: Note (1): [[Vancomycin]] 30–45 mg/kg IV q8–12h could be substituted for nafcillin or oxacillin if the risk of MRSA is high.
* '''Septic thrombosis of cavernous or dural venous sinus'''
::: Note (2): The optimal duration of therapy remains unclear.  A 3– to 4–week course of treatment is usually recommended.
:*1. '''Empiric antimicrobial therapy'''<ref>{{Cite journal| doi = 10.1161/STR.0b013e31820a8364| issn = 1524-4628| volume = 42| issue = 4| pages = 1158–1192| last1 = Saposnik| first1 = Gustavo| last2 = Barinagarrementeria| first2 = Fernando| last3 = Brown| first3 = Robert D.| last4 = Bushnell| first4 = Cheryl D.| last5 = Cucchiara| first5 = Brett| last6 = Cushman| first6 = Mary| last7 = deVeber| first7 = Gabrielle| last8 = Ferro| first8 = Jose M.| last9 = Tsai| first9 = Fong Y.| last10 = American Heart Association Stroke Council and the Council on Epidemiology and Prevention| title = Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association| journal = Stroke; a Journal of Cerebral Circulation| date = 2011-04| pmid = 21293023}}</ref><ref>{{Cite journal| issn = 0003-9926| volume = 161| issue = 22| pages = 2671–2676| last1 = Ebright| first1 = J. R.| last2 = Pace| first2 = M. T.| last3 = Niazi| first3 = A. F.| title = Septic thrombosis of the cavernous sinuses| journal = Archives of Internal Medicine| date = 2001-12-10| pmid = 11732931}}</ref><ref>{{Cite journal| issn = 0022-2151| volume = 107| issue = 9| pages = 803–808| last = Singh| first = B.| title = The management of lateral sinus thrombosis| journal = The Journal of Laryngology and Otology| date = 1993-09| pmid = 8228594}}</ref><ref>{{Cite journal| issn = 0025-7974| volume = 65| issue = 2| pages = 82–106| last1 = Southwick| first1 = F. S.| last2 = Richardson| first2 = E. P.| last3 = Swartz| first3 = M. N.| title = Septic thrombosis of the dural venous sinuses| journal = Medicine| date = 1986-03| pmid = 3512953}}</ref>
::* Preferred regimen: ([[Vancomycin]] 30–45 mg/kg 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 3-4 weeks
::: Note (1): If risk of MRSA is high, [[Vancomycin]] should be administered instead of either nafcillin or oxacillin
::: Note (2): The optimal duration of therapy remains unclear


:* Specific anatomic considerations
:*2. '''Specific anatomic considerations'''
::* '''Cavernous sinus'''
::*2.1 '''Cavernous sinus'''
:::* Preferred regimen: [[Vancomycin]] 30–45 mg/kg IV q8–12h {{and}} ([[Ceftriaxone]] 2 g IV q12h or [[Cefotaxime]] 8–12 g/day IV q4–6h) {{and}} [[Metronidazole]] 7.5 mg/kg IV q6h
:::* Preferred regimen: [[Vancomycin]] 30–45 mg/kg IV q8–12h 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: [[Daptomycin]] 8–12 mg/kg IV q24h {{or}} [[Linezolid]] 600 mg IV q12h could be considered for patients unable to tolerate vancomycin.
:::: Note: [[Daptomycin]] 8–12 mg/kg IV q24h {{or}} [[Linezolid]] 600 mg IV q12h could be considered for patients unable to tolerate vancomycin


::* '''Lateral sinus'''
::*2.2 '''Lateral sinus'''
:::* Preferred regimen: [[Cefepime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8h {{and}} [[Vancomycin]] 15-20 IV mg/kg
:::* Preferred regimen: [[Cefepime]] 2 g IV q8h for 3-4 weeks {{and}} [[Metronidazole]] 500 mg IV q8h for 3-4 weeks {{and}} [[Vancomycin]] 15-20 IV mg/kg for 3-4 weeks
:::* Alternative regimen: [[Meropenem]] 1-2 g IV q8h {{and}} [[Linezolid]] 600 mg IV q12h
:::* Alternative regimen: [[Meropenem]] 1-2 g IV q8h 3-4 weeks {{and}} [[Linezolid]] 600 mg IV q12h 3-4 weeks


::* '''Superior sagittal sinus'''
::*2.3 '''Superior sagittal sinus'''
:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q12h {{and}} [[Vancomycin]] 15–20 mg/kg {{and}} [[Dexamethasone]]
:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q12h for 3-4 weeks {{and}} [[Vancomycin]] 15–20 mg/kg for 3-4 weeks {{and}} [[Dexamethasone]] 10 mg IV q6h continued until symptomatic improvement and tailed gradually over several weeks
:::* Alternative regimen: [[Meropenem]] 1–2 g IV q8h {{and}} [[Vancomycin]] 15–20 mg/kg {{and}} [[Dexamethasone]]
:::* Alternative regimen: [[Meropenem]] 1–2 g IV q8h for 3-4 weeks {{and}} [[Vancomycin]] 15–20 mg/kg for 3-4 weeks {{and}} [[Dexamethasone]] 10 mg IV q6h continued until symptomatic improvement and tailed gradually over several weeks


:* Pathogen-directed antimicrobial therapy
:*3. '''Pathogen-directed antimicrobial therapy'''
::* '''Staphylococcus aureus, methicillin-resistant (MRSA)'''<ref>{{Cite journal| doi = 10.1093/cid/ciq146| issn = 1537-6591| volume = 52| issue = 3| pages = –18-55| last1 = Liu| first1 = Catherine| last2 = Bayer| first2 = Arnold| last3 = Cosgrove| first3 = Sara E.| last4 = Daum| first4 = Robert S.| last5 = Fridkin| first5 = Scott K.| last6 = Gorwitz| first6 = Rachel J.| last7 = Kaplan| first7 = Sheldon L.| last8 = Karchmer| first8 = Adolf W.| last9 = Levine| first9 = Donald P.| last10 = Murray| first10 = Barbara E.| last11 = J Rybak| first11 = Michael| last12 = Talan| first12 = David A.| last13 = Chambers| first13 = Henry F.| last14 = Infectious Diseases Society of America| title = Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2011-02-01| pmid = 21208910}}</ref>
::* '''Staphylococcus aureus, methicillin-resistant (MRSA)'''<ref>{{Cite journal| doi = 10.1093/cid/ciq146| issn = 1537-6591| volume = 52| issue = 3| pages = –18-55| last1 = Liu| first1 = Catherine| last2 = Bayer| first2 = Arnold| last3 = Cosgrove| first3 = Sara E.| last4 = Daum| first4 = Robert S.| last5 = Fridkin| first5 = Scott K.| last6 = Gorwitz| first6 = Rachel J.| last7 = Kaplan| first7 = Sheldon L.| last8 = Karchmer| first8 = Adolf W.| last9 = Levine| first9 = Donald P.| last10 = Murray| first10 = Barbara E.| last11 = J Rybak| first11 = Michael| last12 = Talan| first12 = David A.| last13 = Chambers| first13 = Henry F.| last14 = Infectious Diseases Society of America| title = Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2011-02-01| pmid = 21208910}}</ref>
:::* Preferred regimen: [[Vancomycin]] 15–20 mg/kg/dose IV q8–12h for 4–6 weeks
:::* Preferred regimen: [[Vancomycin]] 15–20 mg/kg/dose 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
:::* 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
:::* Pediatric dose: [[Vancomycin]] 15 mg/kg/dose IV q6h 4–6 weeks {{or}} [[Linezolid]] 10 mg/kg/dose PO/IV q8h 4–6 weeks
:::: Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible.
:::* Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible
:::: Note (2): Consider the addition of [[Rifampin]] 600 mg qd or 300–450 mg bid to vancomycin.
:::* Note (2): Consider the addition of [[Rifampin]] 600 mg qd or 300–450 mg bid to vancomycin

Latest revision as of 19:39, 6 October 2015

  • Cavernous sinus thrombosis is considered a medical emergency.
  • Duration of therapy is usually a total of 3-4 weeks. More prolonged administration of antimicrobial therapy (total of 6-8 weeks) may be indicated among patients who are suspected to have developed complications (e.g. suppurative intracranial disease).
  • ENT surgery must be consulted to evaluate the need of surgical drainage (e.g. sphenoidotomy if sphenoid sinus infection is the primary cause).
  • Septic thrombosis of cavernous or dural venous sinus
Note (1): If risk of MRSA is high, Vancomycin should be administered instead of either nafcillin or oxacillin
Note (2): The optimal duration of therapy remains unclear
  • 2. Specific anatomic considerations
  • 2.1 Cavernous sinus
Note: Daptomycin 8–12 mg/kg IV q24h OR Linezolid 600 mg IV q12h could be considered for patients unable to tolerate vancomycin
  • 2.2 Lateral sinus
  • 2.3 Superior sagittal sinus
  • Preferred regimen: Ceftriaxone 2 g IV q12h for 3-4 weeks AND Vancomycin 15–20 mg/kg for 3-4 weeks AND Dexamethasone 10 mg IV q6h continued until symptomatic improvement and tailed gradually over several weeks
  • Alternative regimen: Meropenem 1–2 g IV q8h for 3-4 weeks AND Vancomycin 15–20 mg/kg for 3-4 weeks AND Dexamethasone 10 mg IV q6h continued until symptomatic improvement and tailed gradually over several weeks
  • 3. Pathogen-directed antimicrobial therapy
  • Staphylococcus aureus, methicillin-resistant (MRSA)[5]
  • Preferred regimen: Vancomycin 15–20 mg/kg/dose 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 4–6 weeks OR Linezolid 10 mg/kg/dose PO/IV q8h 4–6 weeks
  • Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible
  • Note (2): Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin
  1. Saposnik, Gustavo; Barinagarrementeria, Fernando; Brown, Robert D.; Bushnell, Cheryl D.; Cucchiara, Brett; Cushman, Mary; deVeber, Gabrielle; Ferro, Jose M.; Tsai, Fong Y.; American Heart Association Stroke Council and the Council on Epidemiology and Prevention (2011-04). "Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association". Stroke; a Journal of Cerebral Circulation. 42 (4): 1158–1192. doi:10.1161/STR.0b013e31820a8364. ISSN 1524-4628. PMID 21293023. Check date values in: |date= (help)
  2. Ebright, J. R.; Pace, M. T.; Niazi, A. F. (2001-12-10). "Septic thrombosis of the cavernous sinuses". Archives of Internal Medicine. 161 (22): 2671–2676. ISSN 0003-9926. PMID 11732931.
  3. Singh, B. (1993-09). "The management of lateral sinus thrombosis". The Journal of Laryngology and Otology. 107 (9): 803–808. ISSN 0022-2151. PMID 8228594. Check date values in: |date= (help)
  4. Southwick, F. S.; Richardson, E. P.; Swartz, M. N. (1986-03). "Septic thrombosis of the dural venous sinuses". Medicine. 65 (2): 82–106. ISSN 0025-7974. PMID 3512953. Check date values in: |date= (help)
  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.