腦內膿瘍如何使用抗生素治療?

Penny Murata, MD

Penny Murata, MD, is a freelancer for Medscape.

Laurie E. Scudder, DNP, NP

Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC

 

Recommendations Issued for Antibiotic Treatment of Brain Abscess

News Author: Emma Hitt, PhD
CME Author: Penny Murata, MD

Clinical Context

Data on brain abscesses in children have been reported. For example, Goodkin and colleagues reported on historical trends of intracerebral abscesses at Children's Hospital Boston (Pediatrics. 2004;113:1765-1770). However, no guidelines exist for the management of brain abscesses in children.

This retrospective study by Felsenstein and colleagues assesses the bacterial causes of brain abscesses and the recommended empiric treatment, links between preexisting conditions and specific pathogens, and the effect of duration of treatment on outcomes.

Study Synopsis and Perspective

Recommendations regarding antibiotic treatment of brain abscesses in children have been derived as a result of a retrospective clinical audit conducted in British pediatric neurosurgical centers.

Susanna Felsenstein, MRCPCH, with the Department of Paediatric Infectious Diseases, St. George's Healthcare Trust in London, United Kingdom, and colleagues reported the findings and issued recommendations in the September 20 issue of the Pediatric Infectious Disease Journal.

According to the researchers, although rare in children, cerebral abscesses cause significant death and morbidity, but data on the specific clinical characteristics of this condition are limited. "The choice, route and duration of antibiotics for children with brain abscesses are controversial," the researchers wrote. "There are no national or international infectious disease society guidelines in the US or UK for the specific management of children with brain abscesses."

The current study evaluated the effect of various factors on patient outcomes; from that, the researchers formulated recommendations for management of this condition.

The retrospective clinical audit was performed in 4 pediatric neurologic centers in the United Kingdom. A total of 118 children, aged 1 month to 17 years, who presented with a brain abscess within a 10-year period from January 1999 to December 2009 were included in the study.

The radiologic imaging report of every case was reevaluated to confirm the diagnosis. Data regarding the demographics, predisposing conditions, symptoms, diagnostics, interventions, and outcomes were collected. Clinical outcomes were graded as severe neurologic deficit, mild or moderate neurologic deficit, absence of a neurologic deficit, and intellectual impairment.

The audit found that young children (< 5 years old), and patients who presented with a Glasgow Coma Score of less than 8 were associated with having a poor outcome. The audit also found that antibiotic therapy was initiated before diagnosis in 59% of the patients, suggesting that variability in the preceding infection and clinical manifestation of brain abscesses makes diagnosis difficult.

In addition, the audit suggested that the duration between the appearance of symptoms and diagnosis and treatment seemed to have no bearing on the outcome, although this may be because of the retrospective study design. Finally, children with worse outcomes tended to be treated more quickly, indicating that they may have presented with more severe symptoms.

The list of recommendations derived from the study includes the following:

• Initial detection and subsequent monitoring of the abscess should be performed with magnetic resonance imaging.
• The antibiotics ceftriaxone/cefotaxime plus metronidazole should be used for initial treatment of children with confirmed brain abscess.
• In severely ill or immunocompromised patients with poorer outcomes, meropenem, a broad-host-range antibiotic, should be the first-line choice.
• Brain abscesses should be treated with antibiotics for 6 weeks — of which at least 1 to 2 weeks of the treatment should be intravenous — based on improvements in clinical conditions and inflammatory markers.
• Culture results should determine which step-down oral antibiotics are used for subsequent treatment.
• A working party should be established to implement treatment guidelines in children, especially the need for empiric metronidazole therapy.
• These guidelines, as with others, need to be reaudited.

"The strengths of this study lie in the large number of patients included, the multicenter involvement and the comprehensive coverage of cases," the researchers note. The limitations of the study include its retrospective design that resulted in poor documentation in some cases. Furthermore, certain subgroups had very few cases, making statistical analysis impossible.

The study authors have disclosed no relevant financial relationships.

Pediatr Infect Dis J. Published online September 20, 2012.

Study Highlights

• 118 children with brain abscesses were seen at 4 neurosurgical centers in the United Kingdom from 1999 to 2009.
• Inclusion criteria were age 1 month to 17 years with a coded hospital discharge diagnosis of cerebral abscess, subdural empyema, epidural empyema, or brain abscess.
• Exclusion criteria were unavailable medical notes.
• Diagnoses were confirmed by review of a radiologic imaging report.
• 53 (44.9%) had parenchymal cerebral abscess, 39 (33.1%) had subdural empyema, 14 (11.9%) had extradural empyema, and 10 (8.4%) had combined types of abscess.
• The median age was 10 years (age range, 0.1 - 17.8 years), with bimodal peaks at 1.5 and 11.0 years.
• The median age at presentation was 11 years for boys vs 8 years for girls, and 61 (51.7%) were boys.
• The primary outcome measure of neurologic deficit was categorized as severe (hemiparesis, hydrocephalus, visual loss, marked intellectual impairment), mild to moderate (less impairment, including hearing loss, seizures, milder motor problems, mild to moderate intellectual impairment), or none.
• The most common preceding infection was sinusitis (43 children [36.4%]).
• The most common underlying condition was congenital heart disease (11 children [9.3%]).
• Children with meningitis or otitis media vs those with other risk factors were younger (mean age, 3.1 vs 9.4 years and 5.7 vs 9.0 years).
• Children with sinusitis were older (mean age, 11.2 vs 6.7 years).
• Antibiotic treatment before the diagnosis of brain abscess was received by 67 (58.8%) of 114 children.
• The most common symptoms at presentation were nonspecific followed by focal neurologic abnormalities in 53.0 of children%.
• The triad of fever, headache, and focal neurologic deficit occurred in only 13% of children.
• Headache was linked with older children, and fever was linked with younger children.
• The time between onset of symptoms and diagnosis ranged from 0 to 44 days (median, 10 days).
• Magnetic resonance imaging scan was more diagnostic vs computed tomography scan.
• The diagnosis was made in 100% of 12 children who underwent magnetic resonance imaging scan.
• 24.0% of 100 children who underwent computed tomography scan required further imaging.
• Of 97 children with abscess culture results, 83 (85.6%) had a positive culture result.
• The most common pathogen was streptococci in 63 (50.0%) of 126 isolates, with Streptococcus milleri in 38.1%.
• 14 (11.1%) of isolated pathogens were anaerobic bacteria.
• 1 patient had a candida abscess.
• In children with a penetrating head injury or neurosurgical procedure, the most common isolate was Staphylococcus aureus.
• The recommended empiric antibiotic treatment is ceftriaxone/cefotaxime plus metronidazole, which would have provided adequate coverage in 82.7% of patients.
• Ceftriaxone/cefotaxime would have treated at least 76.5% of patients.
• Metronidazole would have added coverage for up to 7% of patients.
• Carbapenem would have treated 89.7% of children.
• For children with head trauma, antistaphylococcal coverage is recommended.
• The most frequent duration of antibiotic use was 6 weeks in 40.6% of children (mean, 51 days; range, 5 - 176 days).
• The route of antibiotics was intravenous for an average of 28 days (range, 5 - 70 days) and oral for an average of 20 days (range, 0 - 117 days).
• The mortality rate was 5.9% overall and 33.3% in immunosuppressed patients.
• Of 93 children at 6-week follow-up, 60 (64.5%) had no new deficit, 21 (22.5%) had mild to moderate deficit, and 12 (13.0%) had severe deficit.
• Of 66 children at 6-month follow-up, 2 (3.0%) had deteriorated, and 10 (15.2%) improved.
• Poor outcome at 6 months was associated with age younger than 5 years and a Glasgow Coma Score of 8 or less.
• Study limitations were retrospective design, poor documentation of outcomes, and small sample size for some subgroups.

Clinical Implications

• In children with brain abscesses, the recommended empiric treatment is ceftriaxone/cefotaxime plus metronidazole. Metronidazole might not be needed in some patients. Antistaphylococcal coverage is recommended for children with head trauma.
• In children with brain abscesses, poor outcome at 6 months is linked with age younger than 5 years and a Glasgow Coma Score of 8 or less.