Treatment Of Brain Abscess Research Articles

Aminoglycosides

Aminoglycoside antibiotics are primarily active against aerobic Gram-negative bacilli. In practical pediatric therapy, they are used most frequently on an empiric basis in clinical situations where the risk of a Gram-negative enteric infection is significant enough to warrant patient protection before the actual confirmation or identification of an offending organism. Synergistic effects with penicillins or cephalosporins have made aminoglycosides valuable in the early stages of therapy. Although the potential for toxicity with aminoglycosides is both real and significant,their use in pediatric practice continues to be popular.Aminoglycosides frequently are indicated in several major pediatric circumstances: treatment of fever with potential sepsis in the neonate, presumptive upper urinary tract infections, and acute exacerbations of cystic fibrosis.The physiologic “relative” immunosuppression of young infants in the first few months of life place them at great risk for rapid, overwhelming sepsis or meningitis, which may manifest with only fever or minor symptoms early in the clinical course. The emergence of group B streptococci as a frequent cause of infection, in addition to the continuing possibility of infection with Gram-negative bacilli (especially Escherichia coli) and the unlikely but possible presence of Listeria monocytogenes, has reinforced the common use of an aminoglycoside/ampicillin combination. It is particularly useful while awaiting results of microbiologic culture and sensitivity testing.Single-course aminoglycoside therapy for symptomatic patients who have cystic fibrosis is also effective, usually when administered parenterally. With treatment, both a reduction in Pseudomonas organisms found in sputum and an improvement in acute symptoms has been documented.Aminoglycosides may be appropriate when pyelonephritis is suspected on the basis of clinical evaluation and initial, nonconfirmatory, laboratory data. These antibiotics achieve high concentrations in the renal parenchyma and the urine. The risks associated with untreated urinary tract infections and the increasing resistance of E coli to other first-line antibiotic therapy justify consideration of gentamicin or other aminoglycosides as part of early treatment of renal infection.Other routine clinical indications for aminoglycosides include necrotizing enterocolitis and aspiration pneumonia in newborns, pneumonia caused by Gram-negative pathogens, bowel perforation, early treatment of brain abscess, empiric treatment of febrile neutropenia, and suspected Pseudomonas infection. Combination antibiotic therapy is recommended initially for most of these situations.The potential for toxicity with aminoglycosides is significant, and underlying renal function must be monitored when administering these agents. Glomerular and tubular nephrotoxicity is greater in patients who have impaired renal function and in those receiving high doses or prolonged therapy. Signs of toxicity may include new-onset presence of casts, cells, or protein in the urine; rising blood urea nitrogen and serum creatinine levels; and oliguria.Eighth nerve function also must be monitored. Auditory and vestibular damage can be mild and reversible or severe and permanent, usually based on dosage and prolongation of therapy. Symptoms may be delayed in onset after completion or discontinuation of therapy. A sensation of ear fullness and tinnitus may progress to hearing impairment or deafness. Problems with equilibrium, nystagmus, or vertigo may follow vestibular damage. Young patients are generally at lower risk for toxicity than the elderly.Other side effects may include neuromuscular blockade, neuropathy, elevation of serum transaminases, hypomagnesemia, and eosinophilia.For most patients, side effects are mild and reversible upon discontinuation of treatment. Ongoing monitoring of the duration of therapy, peak and trough serum drug levels, state of hydration, and total dose administered can decrease the risk. Attention to pharmacokinetics based on age is also important; serum half-life is much higher in the first month of life and particularly in preterm infants of low birthweight. This is due both to a larger volume of distribution and to decreased clearance. Dosage strength and frequency may need to be reduced.Aminoglysides, while potentially quite toxic, may be of great therapeutic benefit in pediatric care when monitored judiciously,particularly in the early therapy of potentially serious infection.

Current treatment of brain abscess in patients with congenital cyanotic heart disease.

The goal of this study was to define clearly the role of management in patients with cyanotic heart disease and brain abscesses by evaluating retrospectively the factors influencing poor outcome in these patients. This study included 62 patients with cyanotic heart disease and brain abscesses diagnosed in the computed tomography era. Basic characteristic parameters (number, size, location, computed tomographic classification and organism type of abscess, convulsion, type of cyanotic heart disease, age distribution, immunocompromised status, pretreatment neurological state, and intraventricular rupture of brain abscess [IVROBA]) and therapeutic parameters (type of antibiotics and duration of administration, steroid medication and therapeutic modalities, aspiration with or without cerebrospinal fluid drainage, total extirpation after aspiration, or primary extirpation and medical treatment) were evaluated as independent predictors of poor outcome (totally disabled state or death) by using univariate and multivariate logistic regression analysis. We also statistically estimated the possible causes of IVROBA and the multiplicity of brain abscess. Although there were no statistically significant correlations between patients with good and poor outcomes in regard to other basic characteristic and therapeutic parameters, patients with poor outcomes were older (P < 0.02), more frequently had IVROBA (P < 0.005), and had a higher frequency of neurological deterioration (P < 0.01) than those with good outcomes. Multiple logistic regression analysis predicted that poor outcome increased the relative risk of IVROBA by a factor of 18.9 (odds rate, 18.9; 95% confidence interval, 1.7-211.6; P < 0.02). More patients with multiple abscesses had positive immunocompromised states than those with single abscesses (P < 0.01). Deep-located abscesses also more frequently had IVROBA (P < 0.005) and abscesses located in the parieto-occipital region ruptured into the occipital horn of the lateral ventricle in a short period (P < 0.02). Our findings suggest that IVROBA strongly influences poor outcome in patients with cyanotic heart disease. The key to decreasing poor outcomes may be the prevention and management of IVROBA. To reduce operative and anesthetic risk in these patients, abscesses should be managed by less invasive aspiration methods guided by computed tomography. Abscesses larger than 2 cm in diameter, in deep-located or parieto-occipital regions, should be aspirated immediately and repeatedly, mainly using computed tomography-guided methods to decrease intracranial pressure and avoid IVROBA. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with the appropriate intravenous and intrathecal administration of antibiotics while evaluating intracranial pressure pathophysiology.

P-6-711 - Dianostics and surgical treatment of brain abscess in children

P-6-711 - Dianostics and surgical treatment of brain abscess in children

Imipenem therapy of brain abscesses.

The efficacy of imipenem versus standard chemotherapy (both in addition to neurosurgery) in the treatment of brain abscess was compared in a retrospective study. Cure was obtained in 52 of 60 (86.7%) patients in the standard group, and in 15 of 15 (including 5 patients with multiple brain abscesses) in the imipenem group. Cure without neurosurgery was observed in 2 of 60 (3.3%) and 3 of 15 (20%) of the cases, respectively (p = 0.08). Levels of imipenem in blood, cerebrospinal fluid, and brain pus were above the minimum inhibitory concentrations of most of the abscess isolates. Side effects of imipenem were rare and tolerance was excellent. Imipenem monotherapy (3-4 g/day) for five weeks seems a reasonable therapeutic choice for treatment of bacterial brain abscesses.

William Macewen and the treatment of brain abscesses: revisited after one hundred years

The year 1993 marked the centennial of the publication of Sir William Macewen's monograph, Pyogenic Infective Diseases of the Brain and Spinal Cord, and its accompanying volume, Atlas of Head Sections. As Harvey Cushing noted, the text on pyogenic diseases of the brain was a landmark in surgery of the nervous system. At the time of its publication, Macewen's work was the most comprehensive study of pyogenic brain diseases. In this paper the author reviews the state of knowledge of brain abscess existing in the 19th and 20th centuries, with particular emphasis on the late 19th century, and elucidates factors contributing to Macewen's remarkable success. His thorough knowledge of the natural history of pyogenic diseases of the temporal bone and nasal sinuses, in addition to his clear description of cranial anatomy, as illustrated in his Atlas of Head Sections, were especially important in developing his successful treatment of brain abscess. The x-ray had not yet been discovered; Macewen's diagnosis was based on clinical findings superbly illustrated by his three clinical stages of brain abscess development. His clinical observations are as relevant today as when he described them 100 years ago. Macewen recorded 25 cases of brain abscess. Nineteen of these patients came to his attention in time to undergo surgery, resulting in 18 recoveries. All five of his patients with extradural abscess recovered. These results were achieved in the era known as "the most glorious period in British surgery." Neurosurgery was in its infancy; nevertheless, even as the 20th century closes, Macewen's results still have not been surpassed.

Factors that enhance the likelihood of successful stereotactic treatment of brain abscesses.

Successful clinical outcomes are not achieved in all patients who undergo image-guided stereotactic surgery as the initial procedure in the management of brain abscess. We sought to define those factors related to management failure, so that the initial surgical approach could be selected using preoperative clinical or imaging criteria. We reviewed our twelve-year experience in 29 consecutive patients. Twenty-two (76%) patients had drainage of abscesses with purulent centers. Seven (24%) underwent lesion biopsy for diagnosis. Twelve patients (with abscesses > 3 cm in average diameter) underwent stereotactic insertion of drainage catheters. Ten patients (34%) had adverse risk factors including immunologic suppression after prior organ transplantation, chronic steroid therapy, prior antineoplastic chemotherapy, or retained foreign body. Microbiological identification of the causative organism was obtained in 22 patients; 6 patients had positive Gram stains without growth in culture (bacteriological diagnosis = 97%). Long-term clinical evaluation (up to 8.5 years, median 3 years) confirmed disease resolution after initial single-procedure stereotactic management in 21 patients (72%). Eventual abscess resolution occurred in an additional 6 patients (21%), all of whom required multiple procedures. Five patients died of complications of their systemic disease during the follow-up period. Fifteen of the 18 (83%) surviving patients who had no associated risk factors returned to their premorbid functional capacity. Factors associated with initial treatment failure included inadequate aspiration, lack of catheter drainage of larger abscesses, chronic immunosuppression, and insufficient antibiotic therapy.

Multiple Brain Abscesses at King Khalid University Hospital

The authors reviewed six cases of multiple brain abscesses that were treated at King Khalid University Hospital (KKUH) over an eight year period. This represented 22% of the total brain abscesses treated during the same period. The series is unusual in that the infective pathogens were fungi (Fonsecaea pedrosoi) in two patients (33%) and an aerobic actinomycete (Nocardia asteroides) in one patient (16%). Two patients treated elsewhere with antibiotics empirically for one month died at three and 28 days following admission. The poor outcome was probably related t the delay in obtaining a microbiological diagnosis and commencing the appropriate antimicrobial therapy. The importance of early identification of the pathogen in patients with multiple brain abscesses is stressed.

Treatment of Brain Abscess with Cefotaxime and Metronidazole: Prospective Study on 15 Consecutive Patients

The aim of the present investigation was to prospectively study the clinical and bacteriologic outcome of 15 consecutive patients with brain abscesses who were treated with surgical excision and cefotaxime (3 g every 8 hours) plus metronidazole (0.5 g every 8 hours) for at least 3 weeks. The patients were followed clinically and with computed tomographic (CT) examinations. All patients survived, and there were no recurrences within 1 year. CT scans showed an exponential decrease in the size of enhancement. Cultures of all six specimens obtained after < 24 hours of treatment with cefotaxime and metronidazole were positive compared with cultures of three of nine specimens obtained later (P = .017). Anaerobic bacteria were isolated from 2 of 3 patients given two doses of metronidazole or less compared with none of 12 given three doses or more (P = .029). Reversible side effects occurred in nine patients. It is concluded that cefotaxime plus metronidazole is an alternative treatment for brain abscess in addition to surgical excision because of their good abscess penetration, their ability to eradicate bacteria, and a good clinical outcome.

CT-guided stereotactic aspiration and treatment of brain abscesses. An experience with 24 cases.

The present study reports our experience with stereotactic puncture, aspiration and drainage of brain abscesses in 24 patients from a series of 34 consecutive cases. In all patients an intracavitary catheter was left in place for external drainage and daily irrigation with antibiotics. The patients received pre- and postoperatively triple broad spectrum antibiotic treatment, associated with low dose steroids and anti-epileptic drugs. Follow-up CT scans showed immediate reduction of the abscess size and gradual diameter diminution of the enhancing ring structure until its disappearance. The clinical presentation, risk factors, aetiology, outcome, bacteriological and CT findings were analysed. Mortality in this series was 4%. The majority of patients (96%) had no or minimal disability according to the Glasgow Outcome Scale. Our results confirm the value of this treatment policy and suggest that the stereotactic technique is a simple and safe method with minimal mortality and morbidity in the treatment of the majority of chronic brain abscesses.

Non-traumatic brain abscess

Between 1953 and 1989 eighty cases of non-traumatic brain abscess were treated in our department. We have re-examined the clinical and neuroradiological features of this pathological process and present our therapeutic approach and results. We believe that the optimal treatment for brain abscess consists of surgical removal. The prognosis for these lesions has undergone a marked improvement over the last two decades in response to neuroradiological, microbiological and surgical advances. The most influential prognostic factor seems to be preoperative clinical status.

Penetration of cefotaxime and desacetylcefotaxime into brain abscesses in humans

Since clinical trials comparing the efficacies of different antibiotic regimens for treatment of brain abscesses are difficult to perform, the choice of antibiotics must rely on the antibacterial spectrum and the ability of the drug to penetrate into the abscess fluid. The aim of this investigation was to study the ability of cefotaxime and its active metabolite desacetylcefotaxime to penetrate into brain abscesses. Eight patients were given 3 g of cefotaxime intravenously every 8 h. Abscess fluid samples, obtained at surgery at various times after dosing, and blood samples were analyzed for their concentrations of cefotaxime and desacetylcefotaxime by using a newly developed microbiological assay. The brain abscess concentrations of cefotaxime and desacetylcefotaxime were 1.9 +/- 1.7 and 4.0 +/- 2.2 mg/liter, respectively. Simultaneous concentrations in plasma were 2.0 +/- 1.0 and 3.9 +/- 1.8 mg/liter, respectively. With increasing time following cefotaxime dosing there was a significant increase in the abscess:plasma concentration ratio of desacetylcefotaxime. Since both cefotaxime and desacetylcefotaxime penetrate well into the brain abscess, reaching concentrations above the MIC for probable bacteria except gram-negative anaerobes, it is concluded that cefotaxime in combination with metronidazole may be used as an alternative in the treatment of brain abscesses.

Epilepsy following brain abscess. The evaluation of possible risk factors with emphasis on new concept of epileptic focus formation

The study is based on follow-up data of 108 patients treated for brain abscess (mean follow-up period 11 years). The overall incidence of epilepsy was 34% (37% in supratentorial lesions). The author compared the incidence of several parameters between two groups of patients: those presenting, and those not presenting with epilepsy after brain abscess treatment. Parameters characterized by significantly different incidence in each group were taken into account as possible risk factors influencing the development of epilepsy. Sex, age of the patient, localisation and size of the abscess are discussed as presumptive risk factors modifying prediction to epilepsy. The author presents a new concept of epileptic focus formation to explain satisfactorily the results of the study on the basis of pathological mechanisms. A protocol, which may be useful to evaluate the prediction to epilepsy after brain abscess treatment is proposed.

The value of different methods of treatment of brain abscess in the CT era

67 cases of brain abscess were analyzed retrospectively. As 2 comatose patients died on admission before any treatment was started, the results are based on 65 treated patients. Different methods of treatment included: total removal in 36 patients, drainage in 14, aspiration in 6 and conservative treatment in 9. Management mortality was 18.5% and was almost not dependent on the method of treatment (except aspiration) being lowest in the drainage group. The mortality was significantly higher in patients with serious impairment of consciousness on admission. Follow-up examination after 1 to 11 years was performed in 47 out of 53 discharged patients and revealed in 25 of them (53%) full recovery. 10 additional cases (21%) are independent. The best early and long term results were obtained in patients by drainage and medical treatment. Chronic epilepsy developed in 34% of patients with supratentorial lesions. The risk of epilepsy was lowest in the group of patients treated by drainage. The authors present the opinion that removal of brain abscess is necessary only in exceptional cases.

Treatment of brain abscess

Disponibilite des antibiotiques au niveau de l'encephale pour le traitement des abces du cerveau. Synthese des travaux faisant etat de la penetration des antibiotiques dans le tissu encephalique et l'abces

Brain abscess in the 1980s

Brain abscess was reviewed in 24 patients admitted to University Hospital, Nottingham over a period of 3 years. Chronic ear infection was the most common predisposing factor, but in 11 patients the focus of infection remained unknown. CT scanning, carried out in all patients, was negative in one patient with clinical signs of meningitis. Polymicrobial and anaerobic infections were common. Actinomyces species were isolated in mixed culture from seven patients; in five the abscess was located in the cerebellum. Therapy was most often a combination of surgical drainage and antimicrobial therapy with beta-lactam agents and metronidazole. Evidence suggests that cefotaxime may offer a suitable alternative to chloramphenicol and benzylpenicillin in the treatment of brain abscess.

Quinolone Therapy for Infections of the Central Nervous System

The rationale for use of quinolones in the treatment of central nervous system (CNS) infections is reviewed. Quinolones exert potent activity in vitro against many gram-negative meningeal pathogens. Given the concentrations attained in cerebrospinal fluid (CSF), however, activity against gram-positive organisms is marginal. As a group, the quinolones enter (penetrate) the CSF better than do any other class of antimicrobial agents. The percentage penetration into CSF is remarkably similar in animal models and in humans with meningitis receiving concurrent therapy. The relative rank order for CSF penetration is as follows: enoxacin and pefloxacin (approximately 50%) greater than ciprofloxacin and ofloxacin (approximately 20%-30%). Certain quinolones have proven to be equivalent to conventional agents (e.g., third-generation cephalosporins) in the rate with which they eradicate bacterial gram-negative organisms from the CSF in experimental animal models of meningitis, but the serum concentrations have usually been higher than those achieved in humans. Despite these advantages, the concentrations in CSF remain low (e.g., ciprofloxacin, approximately 0.25-0.5 mg/L; pefloxacin, 4-8 mg/L) in humans because of the relatively low concentrations attained in serum. Thus, quinolones will continue to be most useful in the treatment of infections due to problem pathogens or to multiresistant pathogens (e.g., Pseudomonas species). Although quinolones appear to enter brain tissue readily, it is unlikely that they can be used as single agents for the treatment of brain abscess because of poor activity against anaerobes and streptococci, and no animal or human studies have been reported. A single dose of ciprofloxacin administered orally appears promising for use in eradication of the meningococcal carrier state.

Neurological and behavioral sequelae in children operated on for brain abscess.

In order to characterize neurological, intellectual and behavioral sequelae better after surgical treatment of brain abscess in childhood, 32 children were studied over a 10-year time span after treatment of a brain abscess. Depending on the clinical condition, surgical treatment consisted of simple aspiration through a burr hole or of total excision after craniotomy. There were only 3 postoperative deaths (9%). The scheduled time for long-term follow-up was 3 years after surgery. The patient assessment included information concerning the presence of seizures, accurate neurological examination, an EEG, and a battery of intellectual tests to evaluate the presence of behavioral-mental deficits. Late seizures developed in 7 of the 29 survivors. Five patients presented permanent hemiparesis after surgical treatment. It is noteworthy that the intellectual impairment observed was more severe in younger patients, while the behavioral disturbances were more marked in school-age children.

Treatment of Brain Abscess

Treatment of Brain Abscess

Surgical treatment of brain abscess

Surgical treatment of brain abscess

Surgical treatment of brain abscess.

The author reviews the methods of surgical treatment of brain abscess. All methods are grouped into the following six categories: tube drainage, marsupialization, the migration method of Kahn, tapping only, aspiration, and excision. At present, only two methods are used: aspiration and excision. Antibiotics and computed tomographic (CT) scanning play important roles in the surgical treatment of a brain abscess. The use of CT scanning is invaluable in the management of brain abscess for early and exact localization, assessment of the adequacy of operation, and sequential follow-up.