So, the initial management for
lesions that are greater than 2 cm
are going to be surgical excision.
But remember, we need a well-
formed abscess to surgically excise it
and they do that with stereotactic aspiration.
empirical therapy is going to
be based on the predisposing condition.
The microscopy of abscess contents,
results of blood cultures,
and certainly many of these patients
would be given phenytoin to prevent seizures.
So, the initial management of a brain abscess
was going to be six to eight weeks of IV therapy,
most likely two to three months of oral treatment,
but it does depend.
If it's mixed infection,
we’re going to start
with high-dose IV penicillin.
You need the highest dose to
cross the blood-brain
barrier and penetrate the abscess
or maybe a third-generation cephalosporin.
And we’re going to
add metronidazole to that.
It gets spectacular levels in brain parenchyma
and it is probably the best agent
we have as a single agent for anaerobes.
If we know it’s Staph aureus
on the basis of the Gram stain,
we’re going to give
IV vancomycin until we find
out whether it's MRSA or not.
If it's not MRSA, we can back off
to a more narrow
spectrum nafcillin or oxycillin.
Now, if the patient
has a penicillin allergy,
at a cephalosporin
which penetrates into the spinal fluid
better than other cephalosporins.
If it Pseudomonas aeruginosa
we’re talking about ceftazidime
and the Gram stain would show you
myriads of gram-negative rods.
the gold standard is going to be six to eight weeks again of
IV therapy, followed by months.
Now, if it’s Nocardia,
we’re going to start with trim sulfa.
And the total duration of therapy is going to be
actually 12 months
If the patient
has a treatment failure,
we may have to add a carbapenem,
a third-generation cephalosporin,
minocycline or Linezolid.
If it's of unclear etiology,
we need vancomycin
to cover the staphylococci.
We need metronidazole
to cover the anaerobes.
And we need ceftriaxone to cover
the aerobic gram-negative rods.
If we’re worried about Pseudomonas,
then we would change
from ceftriaxone to cefepime
for that particular organism.
If it's a fungal brain abscess
and we have evidence of,
we start out with liposomal
amphotericin B plus flucytosine.
And then when the
patient is stable or improving,
we switch over to fluconazole.
If it's Aspergillus or Scedosporium,
the drug of choice is
going to be voriconazole.
And that is given until there is absolutely
no evidence of a brain abscess.
For the zygomycetes,
we’re going to use –
and these are the bread molds,
we’re going to be using amphotericin B.
after the patient has improved,
transitioning to an azole
known as posaconazole.
Some people suggest we
should use hyperbaric oxygen,
but the studies demonstrating the effectiveness
of this therapy are rather small,
and so that remains controversial.
For Toxoplasma gondii,
it's pyrimethamine plus
sulfadiazine for at least six weeks,
followed by suppressive therapy.
If the patient is allergic to sulfur drugs,
we use clindamycin.
For Taenia solium
this is controversial.
What you're looking at are the cysts,
the tissue cysts from cysticercosis.
And by the way,
if a Mexican immigrant comes into the United States
and has a first time seizure as an adult,
this is the most common cause of that.
So, cysticercosis should be suspected.
But at any rate, if this diagnosis is made,
you have to remember that some
of these cysts contain living organisms.
So, if you give them
something that would kill the organism,
you are going to create a tremendous
amount of inflammation and brain swelling.
So, the brain inside that solid
skull doesn't have any room to swell,
so you may actually cause
increased intracranial pressure and herniation.
So, it's very, very controversial as
to whether to treat it at least initially.
Most people recommend that you start albendazole or
or praziquantel and then
you give dexamethasone.
And that brings me to my conclusion
of speaking about brain abscess.