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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 for [[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}}</re> |
| 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.
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| Because the etiologic agents responsible for the subdural empyema are generally different, in the intracranial and spinal types, the treatments will be different as well: <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>
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| *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]]
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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===
| | {{ID-Subdural empyema}} |
| Initial [[antibiotic]] therapy should be directed to ''[[Staphylococcus aureus]]'' and ''[[Streptococci]]'' and should include [[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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| ==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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| *The dosage may need to be adjusted in patients suffering from kidney or liver disease.<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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| ===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]]), along with risk of [[anaphylaxis]], [[Stevens-Johnson syndrome]], [[neutropenia]] and [[thrombocytopenia]]<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>, 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===
| | ==Other Pharmacologic Therapies== |
| *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.
| | *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. |
| *Used for prophylaxis and treatment of certain [[bacteria]].
| | *Depending on the severity of the disease and the degree of neurological sequelae, [[physical therapy|physical]] and/or [[speech therapy]] might also be required.<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> |
| *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 pump 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]], [[encephalopathy]], [[cerebellar ataxia]], [[neutropenia]]<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> and association with [[thrombophlebitis]], when administered intravenously.
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| *Its use may cause darker red [[urine]].
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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== | |
| *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. | |
| *Depending on the severity of the disease and the degree of neurological sequelae, [[physical therapy|physical]] and/or [[speech therapy]] might be needed.<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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| ===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.<ref name="pmid15208697">{{cite journal| author=Rogawski MA, Löscher W| title=The neurobiology of antiepileptic drugs. | journal=Nat Rev Neurosci | year= 2004 | volume= 5 | issue= 7 | pages= 553-64 | pmid=15208697 | doi=10.1038/nrn1430 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15208697 }} </ref>
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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]], [[rash]] and is also known for causing drug-induced [[lupus]] and reversible [[IgA deficiency]].
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| ==Antimicrobial Regimen==
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| {{ID-Subdural empyema}}
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| ==References== | | ==References== |