From the Guidelines
Brain abscess treatment should prioritize neurosurgical aspiration or excision as soon as possible in all patients whenever feasible, along with empirical antimicrobial therapy using a 3rd-generation cephalosporin combined with metronidazole. This approach is based on the most recent and highest quality evidence from the European Society of Clinical Microbiology and Infectious Diseases guidelines on diagnosis and treatment of brain abscess in children and adults 1.
Key Considerations
- Neurosurgical intervention is crucial for draining the abscess, especially for lesions larger than 2.5 cm or those causing significant mass effect, as it confirms the diagnosis, identifies the pathogen, and decreases the intra-cavitary bacterial load 1.
- Empirical antimicrobial therapy should include a 3rd-generation cephalosporin combined with metronidazole, as recommended for community-acquired brain abscess, to cover common causative organisms including streptococci, anaerobes, and Staphylococcus aureus 1.
- Antimicrobial therapy typically continues for 6-8 weeks, with the first 2-3 weeks administered intravenously followed by oral antibiotics based on culture results and clinical response 1.
- Regular neuroimaging, preferably MRI, should be performed to monitor treatment response 1.
- Anticonvulsant therapy may be required if seizures occur, with levetiracetam often used as first-line treatment 1.
Diagnostic Approach
- Brain MRI, including DWI/ADC and T1 weighted imaging with and without gadolinium, is the preferred imaging modality for patients with suspected brain abscess, due to its high sensitivity and specificity 1.
- Molecular-based diagnostics may be used if available, especially in patients with negative cultures, to aid in the identification of the causative organism 1.
Management Principles
- Prompt medical attention is essential for brain abscess treatment, as delayed diagnosis and treatment can lead to permanent neurological damage or death.
- Multidisciplinary approach, involving neurosurgeons, infectious disease specialists, and other healthcare professionals, is crucial for optimal patient outcomes.
From the Research
Definition and Causes of Brain Abscess
- Brain abscess is an uncommon and potentially life-threatening infection of the CNS that can be caused by a range of different pathogens including bacteria, fungi, and parasites 2.
- The epidemiology of brain abscess has changed in recent decades, with an increasing incidence, especially among elderly individuals 3.
- Important predisposing conditions include dental and ear-nose-throat infections, immuno-compromise, and previous neurosurgery 3.
Diagnosis of Brain Abscess
- The diagnosis relies upon a combination of magnetic resonance imaging, neurosurgical aspiration or excision, and careful microbiological examinations 3.
- Molecular-based diagnostics have improved our understanding of the involved microorganisms and oral cavity bacteria including anaerobes are the predominant pathogens 3.
Treatment of Brain Abscess
- A multidisciplinary approach is important and anti-infective treatment remains crucial 2.
- Empiric treatment of bacterial brain abscess consists of cefotaxime and metronidazole with the addition of vancomycin if meticilline-resistant Staphylococcus aureus is suspected 2.
- For severely immuno-suppressed patients, voriconazole and trimethoprim-sulfamethoxazole or sulfadiazine should be added 2.
- Meropenem monotherapy is as effective as and safer than imipenem to treat brain abscesses 4.
- Local source control by aspiration or excision of brain abscess combined with long-term antimicrobials are cornerstones of treatment 3.
- Sequential intravenous/oral antibiotic therapy may be an acceptable alternative in selected cases 5.
Management and Outcome
- Long-term management remains important and should address neurological deficits including epilepsy, timely diagnosis and management of comorbidities, and potential affective disorders 3.
- A multidisciplinary approach to acute and long-term management of brain abscess remains crucial and source control of brain abscess by neurosurgery should be pursued whenever possible 3.
- The penetration of cefotaxime and its active metabolite desacetylcefotaxime into brain abscesses is significant, making cefotaxime a potential treatment option 6.