Abstract
BackgroundPaediatric focal intracranial suppurative infections are uncommon but cause significant mortality and morbidity. There are no uniform guidelines regarding antibiotic treatment. This study reviewed management in a tertiary healthcare centre in the United Kingdom and considers suggestions for empirical treatment.MethodsA retrospective, single-centre cohort review of 95 children (< 18 years of age) with focal intracranial suppurative infection admitted between January 2001 and June 2016 in Newcastle upon Tyne, United Kingdom. Microbiological profiles and empirical antibiotic regimens were analysed for coverage, administration and duration of use. Mortality and neurological morbidity were reviewed. Data was analysed using t-tests, Mann-Whitney U tests, independent-samples median tests, and χ2-tests where appropriate. P-values < 0.05 were considered statistically significant.ResultsEstimated annual incidence was 8.79 per million. Age was bimodally distributed. Predisposing factors were identified in 90.5%, most commonly sinusitis (42.1%) and meningitis (23.2%). Sinusitis was associated with older children (p < 0.001) and meningitis with younger children (p < 0.001). The classic triad was present in 14.0%.43.8% of 114 isolates were Streptococcus spp., most commonly Streptococcus milleri group organisms. Twelve patients cultured anaerobes.Thirty one empirical antibiotic regimens were used, most often a third-generation cephalosporin plus metronidazole and amoxicillin (32.2%). 90.5% would have sufficient cover with a third generation cephalosporin plus metronidazole. 66.3% converted to oral antibiotics. Median total antibiotic treatment duration was 90 days (interquartile range, 60–115.50 days).Mortality was 3.2, 38.5% had short-term and 24.2% long-term neurological sequelae.ConclusionsPaediatric focal intracranial suppurative infection has a higher regional incidence than predicted from national estimates and still causes significant mortality and morbidity. We recommend a third-generation cephalosporin plus metronidazole as first-choice empirical treatment. In infants with negative anaerobic cultures metronidazole may be discontinued.
Highlights
MethodsA retrospective, single-centre cohort review of 95 children (< 18 years of age) with focal intracranial suppurative infection admitted between January 2001 and June 2016 in Newcastle upon Tyne, United Kingdom
Focal intracranial suppurative infections are serious conditions rarely seen in children. [1,2,3,4,5] They are divided in three categories: brain abscess (BA), subdural empyema (SDE), and extradural empyema (EDE)
The classic triad consisting of headache, fever, and focal neurological deficits is reported in 8.4–20% of children. [3, 12, 14, 18] Treatment is multidisciplinary consisting of antibiotics and neurosurgery. [3, 5] Neurosurgical intervention aids pathogen identification, reduces lesion size and decompresses, aiming to reduce effects on surrounding structures. [19]
Summary
This single-centre retrospective cohort study reviewed paediatric patients with BA, SDE, and EDE, admitted to the Great North Children’s Hospital (GNCH), a tertiary healthcare centre for paediatric infectious diseases and neurosurgery in the North East of England between January 2001 and June 2016. Patient identification Eligible cases were identified by assessing the paediatric infectious diseases, intensive care (PICU) and neurosurgery records, the previously described local cohort [9], and the hospital clinical coding database. Microbiology Microbiological data was collected from cultures taken during admission. Gram stains of every sample are examined microscopically before culturing and sent for PCR identification if no growth is observed after incubation. Due to changes in the microbiology protocol between 2001 and 2016, not all samples were sent for PCR in growth-negative cases owing to increasing availability of PCR since 2004 only. Distributed data was analysed with unpaired t-tests or one-sample t-tests. Not normally distributed data was analysed with Mann-Whitney U tests and independent-samples median tests.
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