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

Initial treatment includes lowering the intracranial pressure and administering empiric antibiotics. Stereotactic needle biopsy can be performed to obtain tissues for cultures.

A brain abscess greater than 3 cm in diameter should be considered for surgical drainage if accessible, with an exception of tuberculous brain abscess which is treated with anti-tuberculous agents.

  • 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.[1]

Antimicrobial Regimen

Brain abscess

  • Empiric antimicrobial therapy[2][3]
Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.
  • Brain abscess in otherwise healthy patients
  • Brain abscess with comorbidities
  • Otitis media, mastoiditis, or sinusitis
  • Dental infection
  • Penetrating trauma or post-neurosurgy
  • Lung abscess, empyema, or bronchiectasis
  • Bacterial endocarditis
  • Congenital heart disease
  • Transplant recipients
  • Patients with HIV/AIDS
  • Staphylococcus aureus coverage
  • Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h
  • Mycobacterium tuberculosis coverage
  • Pathogen-directed antimicrobial therapy[4][5][6]
Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.
  • Bacteria
  • Actinomyces
  • Bacteroides fragilis
  • Enterobacteriaceae
  • Fusobacterium
  • Haemophilus
  • Listeria monocytogenes
  • Nocardia
  • Prevotella melaninogenica
  • Pseudomonas aeruginosa
  • Staphylococcus aureus, methicillin-resistant (MRSA)
  • 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.
  • Staphylococcus aureus, methicillin-susceptible (MSSA)
  • Streptococcus
  • Fungi
  • Aspergillus
  • Candida
  • Cryptococcus neoformans
  • Mucorales
  • Pseudallescheria boydii (Scedosporium apiospermum)
  • Protozoa
  • Toxoplasma gondii

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. Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  3. Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  4. Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  5. Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  6. 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.