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Brain Abscess Medication

  • Author: Itzhak Brook, MD, MSc; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Oct 05, 2015
 

Medication Summary

The choice of combinations of empiric therapy must cover a broad spectrum of both aerobic and anaerobic bacterial pathogens. Predisposing factors include the following:

  • Otitis, mastoiditis, and sinusitis - Combination of metronidazole or ampicillin-sulbactam plus a third-generation cephalosporin (in those with a predisposing condition)
  • Dental infection - Penicillin plus metronidazole or amoxicillin-sulbactam
  • Pulmonary infections - Penicillin plus metronidazole and a sulfonamide (for Nocardia infections)
  • Congenital heart disease - Third-generation cephalosporin with metronidazole or ampicillin-sulbactam
  • Endocarditis - Vancomycin plus gentamicin in prosthetic valve; ampicillin plus gentamicin or third-generation cephalosporin plus vancomycin in natural valve
  • Intravenous drug abuse - Nafcillin or vancomycin plus cefepime or ceftazidime
  • Penetrating trauma - Vancomycin plus a third-generation cephalosporin
  • Postsurgical - Vancomycin, plus cefepime or ceftazidime, or meropenem
  • Complications of meningitis in infants and children - third-generation cephalosporin, ampicillin, and vancomycin
  • Neonates- third-generation cephalosporin and ampicillin
  • No predisposing condition or the immunocompromised - Metronidazole, vancomycin, or a third-generation or fourth-generation cephalosporin

Vancomycin may be required where MRSA is suspected. Alternatives to vancomycin include linezolid, trimethoprim-sulfamethoxazole, and daptomycin.[42] If methicillin-sensitive S aureus is isolated, vancomycin can be substituted with nafcillin or oxacillin.

Injection of antibiotics into the abscess cavity was advocated in the past in an effort to sterilize the area before operation. However, many antimicrobials penetrate brain abscess cavities fairly well, and instillation of antibiotics into the abscess after drainage is not needed.

The anti-inflammatory effects of corticosteroid therapy can decrease cerebral edema, reducing intracranial pressure. These benefits are offset somewhat by the fact that steroid use decreases antibiotic penetration into the abscess and may slow encapsulation of the abscess site.

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic combinations are usually recommended for serious gram-negative bacillary infections. This approach ensures coverage for a broad range of organisms and polymicrobial infections. In addition, it prevents resistance from bacterial subpopulations and provides additive or synergistic effects. Once organisms and sensitivities are known, the use of antibiotic monotherapy is then recommended.

Ampicillin (Marcillin, Omnipen)

 

Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.

Cefotaxime (Claforan)

 

Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to 1 or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.

Ceftriaxone (Rocephin)

 

Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to 1 or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.

Ceftazidime (Fortaz, Ceptaz, Tazidime)

 

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Chloramphenicol (Chloromycetin)

 

Binds to 50S bacterial ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.

Imipenem plus cilastatin (Primaxin)

 

For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.

Meropenem (Merrem)

 

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci compared to imipenem.

Metronidazole (Flagyl)

 

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis). May be absorbed into the cells, and the intermediate-metabolized compounds that bind DNA are then formed and inhibit synthesis, causing cell death.

Vancomycin (Vancocin)

 

Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients with renal impairment.

Cefepime (Maxipime)

 

Fourth-generation cephalosporin with good gram-negative coverage. Similar to third-generation cephalosporins but has better gram-positive coverage.

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Corticosteroids

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Dexamethasone (Decadron, Dexasone)

 

Corticosteroid of choice for reducing intracranial pressure. Used in treatment of inflammatory diseases. May decrease inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

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Contributor Information and Disclosures
Author

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey D Band, MD, FACP, FIDSA Professor of Medicine, Oakland University William Beaumont School of Medicine; Health System Chair, Healthcare Epidemiology and International Medicine, Beaumont Health System; Former Chief of Infectious Diseases, Beaumont Hospital; Clinical Professor of Medicine, Wayne State University School of Medicine

Disclosure: Nothing to disclose.

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CT scan of a brain abscess.
MRI of a brain abscess.
Brain abscess.
 
 
 
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