What is the treatment for subdural empyema after decompressive craniectomy?

Treatment of Subdural Empyema After Decompressive Craniectomy

Subdural empyema following decompressive craniectomy requires immediate surgical drainage via craniotomy combined with broad-spectrum intravenous antibiotics targeting Staphylococcus aureus, streptococci (including anaerobes), and gram-negative organisms. 1, 2

Immediate Surgical Management

Craniotomy is the preferred surgical approach over burr hole drainage, as it provides superior access to loculated collections and is associated with lower recurrence rates. 2

• Perform urgent craniotomy for evacuation of the subdural empyema, as this represents a neurosurgical emergency requiring prompt decompression 1, 3
• In cases of diffuse or multiloculated empyema, wide craniotomy exposure is necessary to access all infected compartments 4
• Consider placement of subdural drainage catheter for local antibiotic instillation in selected cases 4
• Send all purulent material for both aerobic AND anaerobic cultures, as multiple organisms are frequently present 1, 4

Antibiotic Therapy

Empiric triple antibiotic therapy must be initiated immediately while awaiting culture results. 1

The regimen should include:

• Nafcillin, oxacillin, or vancomycin (for Staphylococcus aureus coverage, particularly methicillin-resistant strains in post-neurosurgical patients) 1, 2, 5
• Third-generation cephalosporin (for gram-negative organism coverage including Pseudomonas aeruginosa and Escherichia coli) 1, 5
• Metronidazole (for anaerobic streptococci coverage, particularly Streptococcus milleri group and Bacteroides species) 1, 4

Post-neurosurgical subdural empyemas commonly harbor Staphylococcus aureus (particularly methicillin-sensitive strains), Staphylococcus epidermidis, Pseudomonas aeruginosa, and various streptococcal species 1, 2, 5

Critical Monitoring and Supportive Care

• Monitor closely for signs of increased intracranial pressure: altered mental status, seizures, focal neurological deficits 3, 2
• Administer seizure prophylaxis, though breakthrough seizures occur in approximately 32% of patients despite prophylaxis 2
• Maintain careful anticoagulation management given the recent decompressive craniectomy—balance thromboembolism risk against bleeding risk 6

Management of Treatment Failure

Approximately 14% of patients require readmission and repeat craniotomy for failed resolution of subdural empyema. 2

• Perform repeat imaging if clinical deterioration occurs or fever persists beyond 48-72 hours of appropriate therapy 2
• Consider repeat craniotomy for persistent or recurrent collections 2
• Reassess antibiotic coverage based on culture sensitivities and clinical response 1

Key Pitfalls to Avoid

• Do not delay surgical intervention—morbidity and mortality correlate directly with delay in treatment 1, 3
• Do not rely on burr hole drainage alone—craniotomy provides better outcomes with lower recurrence rates 2
• Do not omit anaerobic coverage—anaerobic streptococci are among the most common causative organisms 1, 4
• Do not forget to culture for anaerobes—specifically request anaerobic cultures from the microbiology laboratory 1

Prognosis

With aggressive surgical drainage and appropriate antibiotic therapy, full neurological recovery is achievable in most cases, though the clinical presentation triad of headache, fever, and altered sensorium indicates severe disease requiring urgent intervention 4, 2