Can levetiracetam (Keppra) be stopped in a patient with a history of suspected intracranial abscess, who has no evidence of abscess on repeat imaging and no history of seizures?

Discontinuation of Levetiracetam in Suspected Intracranial Abscess Without Confirmed Abscess or Seizures

Yes, levetiracetam should be discontinued in this patient, as primary prophylaxis with antiepileptic drugs is not indicated for patients with suspected but unconfirmed brain abscess who have never experienced seizures. 1

Evidence Against Primary Prophylaxis

The 2024 European Society of Clinical Microbiology and Infectious Diseases guidelines explicitly address this scenario and found insufficient evidence to support primary antiepileptic prophylaxis in brain abscess patients without seizures 1:

• Only one retrospective cohort study met criteria for analysis, examining 103 survivors with confirmed aspirated or excised supratentorial brain abscesses 1
• In that study, 9% of patients developed subsequent epilepsy despite receiving post-discharge antiepileptics for a mean duration of 15 days, compared with 0% of untreated patients (p=0.03) 1
• The guidelines emphasize that primary prophylaxis requires clear benefit to justify treating patients who may never develop seizures, and this benefit has not been demonstrated 1
• Evidence from randomized controlled trials in brain tumors and severe head trauma has been "discouraging" for primary prophylaxis 1

Additional Rationale for Discontinuation in This Case

Your patient has even stronger grounds for discontinuation because:

• No abscess was confirmed on repeat imaging - the original indication (intracranial abscess) was ruled out 1
• No seizures occurred during or prior to admission - the patient never developed the complication that antiepileptics would treat 1
• Unnecessary medication exposure carries risks - levetiracetam can cause psychiatric side-effects, behavioral changes, and rarely aseptic meningitis 1, 2

Supporting Evidence from Brain Tumor Guidelines

The 2021 EANO-ESMO guidelines for brain tumors provide parallel guidance that reinforces this recommendation 1:

• Primary anticonvulsant prophylaxis is not indicated in brain tumor patients (Level I, Grade D evidence) 1
• This applies even to patients with confirmed structural brain lesions, making it even more applicable to your patient without confirmed pathology 1

When Antiepileptics ARE Indicated

Antiepileptic treatment should only be initiated if 1:

• The patient experiences an actual seizure (clinical or electrographic)
• A confirmed brain abscess is present AND the patient has seizures
• Seizures develop during follow-up (which would then be classified as epilepsy requiring treatment)

Common Pitfall to Avoid

Do not continue prophylactic antiepileptics "just to be safe" when the original indication has been ruled out 1. The guidelines specifically note that patient representatives emphasized concerns about "risks of side-effects associated with potentially unnecessary antiepileptics for primary prophylaxis" 1. The balance of evidence favors discontinuation when there is no confirmed structural lesion and no seizure history.

Practical Implementation

• Discontinue levetiracetam immediately - no taper is required for prophylactic dosing 1
• Educate the patient about seizure warning signs and when to seek immediate care
• Document clearly that discontinuation is based on: (1) absence of confirmed abscess on repeat imaging, and (2) absence of any seizure activity