Brain abscess: Difference between revisions
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== Background == |
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===Microbiology=== |
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== Investigations == |
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* MRI |
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** Temporal lobe or cerebellum suggests contiguous spread from chronic otitis or mastoiditis |
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** Frontal lobe suggests contiguous spread from frontal or ethmoid sinusitis |
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** Multiple abscesses in a middle cerebral artery distribution suggests bacteremia |
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== Management == |
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* Empiric therapy is directed at the likely organisms based on etiology (direct vs. hematogenous spread) |
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* For likely oral, ear, or sinus source, treated with [[Is treated by::ceftriaxone]] and [[Is treated by::metronidazole]] at CNS doses |
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* For likely hematogenous spread, treated with [[Is treated by::vancomycin]] |
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* For uncertain etiology, combination of [[ceftriaxone]], [[metronidazole]], and [[vancomycin]] |
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* For neurosurgical patients, [[Is treated by::vancomycin]] plus a broad-spectrum [[Antipseudomonal antibiotics|antipseudomonal antibiotic]] such as [[Is treated by::ceftazidime]], [[Is treated by::cefepime]], or [[Is treated by::meropenem]] |
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[[Category:CNS infections]] |
[[Category:CNS infections]] |
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Revision as of 13:38, 13 August 2020
Background
Microbiology
- Direct spread
- Nose/sinuses: Streptococcus species (especially S. milleri), Haemophilus species, Bacteroides species, Fusobacterium species
- Teeth: Streptococcus species, Bacteroides species, Prevotella species, Fusobacterium species, Haemophilus species
- Ears: Enterobacteriaceae, Streptococcus species, Pseudomonas aeruginosa, Bacteroides species
- Penetrating head trauma: Staphylococcus aureus, Enterobacter species, Clostridium species
- Neurosurgery: Staphylococcus species, Streptococcus species, Pseudomonas aeruginosa, Enterobacter species
- Hematogenous spread
- Lungs: Streptococcus species, Fusobacterium species, Actinomyces species
- Urinary tract: Pseudomonas aeruginosa, Enterobacter species
- Endocarditis: Viridans group streptococci, Staphylococcus aureus
- Congenital cardiac malformations (especially right-to-left shunts): Streptococcus species
- Immunocompromised patient
- HIV: Toxoplasma gondii, Nocardia species, non-tuberculous mycobacteria, Listeria monocytogenes, Cryptococcus neoformans
- Neutropenia: Gram-negative bacilli, Aspergillus species, mucormycosis, Candida species, Scedosporium species
- Transplantation: Aspergillus species, Candida species, mucormycosis, Scedosporium species, Enterobacteriaceae, Nocardia species, Toxoplasma gondii, and Mycobacterium tuberculosis
- Plus anaerobes, which are common
Investigations
- MRI
- Temporal lobe or cerebellum suggests contiguous spread from chronic otitis or mastoiditis
- Frontal lobe suggests contiguous spread from frontal or ethmoid sinusitis
- Multiple abscesses in a middle cerebral artery distribution suggests bacteremia
Management
- Empiric therapy is directed at the likely organisms based on etiology (direct vs. hematogenous spread)
- For likely oral, ear, or sinus source, treated with ceftriaxone and metronidazole at CNS doses
- For likely hematogenous spread, treated with vancomycin
- For uncertain etiology, combination of ceftriaxone, metronidazole, and vancomycin
- For neurosurgical patients, vancomycin plus a broad-spectrum antipseudomonal antibiotic such as ceftazidime, cefepime, or meropenem
Further Reading
- Brain Abscesses. NEJM. 2015;371:447-456. doi: 10.1056/NEJMra1301635
