Brain Abscess: Initial Management

00:01 So, the initial management for lesions that are greater than 2 cm are going to be surgical excision.

00:09 But remember, we need a well- formed abscess to surgically excise it and they do that with stereotactic aspiration.

00:18 And then, empirical therapy is going to be based on the predisposing condition.

00:24 The microscopy of abscess contents, results of blood cultures, and certainly many of these patients would be given phenytoin to prevent seizures.

00:37 So, the initial management of a brain abscess was going to be six to eight weeks of IV therapy, followed by most likely two to three months of oral treatment, but it does depend.

00:49 If it's mixed infection, we’re going to start with high-dose IV penicillin.

00:54 You need the highest dose to cross the blood-brain barrier and penetrate the abscess or maybe a third-generation cephalosporin.

01:02 And we’re going to add metronidazole to that.

01:05 It gets spectacular levels in brain parenchyma and it is probably the best agent we have as a single agent for anaerobes.

01:17 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.

01:28 If it's not MRSA, we can back off to a more narrow spectrum nafcillin or oxycillin.

01:35 Now, if the patient has a penicillin allergy, we’re looking at a cephalosporin like ceftriaxone which penetrates into the spinal fluid better than other cephalosporins.

01:47 If it Pseudomonas aeruginosa we’re talking about ceftazidime or cefepime and the Gram stain would show you myriads of gram-negative rods.

01:59 And so, the gold standard is going to be six to eight weeks again of IV therapy, followed by months.

02:08 Now, if it’s Nocardia, we’re going to start with trim sulfa.

02:14 And the total duration of therapy is going to be actually 12 months for Nocardia.

02:21 If the patient has a treatment failure, we may have to add a carbapenem, a third-generation cephalosporin, minocycline or Linezolid.

02:31 If it's of unclear etiology, we need vancomycin to cover the staphylococci.

02:37 We need metronidazole to cover the anaerobes.

02:40 And we need ceftriaxone to cover the aerobic gram-negative rods.

02:45 If we’re worried about Pseudomonas, then we would change from ceftriaxone to cefepime for that particular organism.

02:55 If it's a fungal brain abscess and we have evidence of, for example, Candida, we start out with liposomal amphotericin B plus flucytosine.

03:06 And then when the patient is stable or improving, we switch over to fluconazole.

03:13 If it's Aspergillus or Scedosporium, the drug of choice is going to be voriconazole.

03:19 And that is given until there is absolutely no evidence of a brain abscess.

03:27 For the zygomycetes, we’re going to use – and these are the bread molds, the Rhizopus, we’re going to be using amphotericin B.

03:36 And then, after the patient has improved, transitioning to an azole known as posaconazole.

03:44 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.

03:58 For Toxoplasma gondii, it's pyrimethamine plus sulfadiazine for at least six weeks, followed by suppressive therapy.

04:08 If the patient is allergic to sulfur drugs, we use clindamycin.

04:12 For Taenia solium causing cysticercosis, this is controversial.

04:23 What you're looking at are the cysts, the tissue cysts from cysticercosis.

04:31 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.

04:46 So, cysticercosis should be suspected.

04:48 But at any rate, if this diagnosis is made, you have to remember that some of these cysts contain living organisms.

04:57 So, if you give them something that would kill the organism, you are going to create a tremendous amount of inflammation and brain swelling.

05:07 So, the brain inside that solid skull doesn't have any room to swell, so you may actually cause increased intracranial pressure and herniation.

05:17 So, it's very, very controversial as to whether to treat it at least initially.

05:25 Most people recommend that you start albendazole or or praziquantel and then you give dexamethasone.

05:36 And that brings me to my conclusion of speaking about brain abscess.