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Intracranial Epidural Abscess Medication

  • Author: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS; Chief Editor: Niranjan N Singh, MD, DM  more...
Updated: Nov 12, 2014

Medication Summary

Until the culture and sensitivity report of the infectious agent becomes available, choice of empiric antibiotic therapy should be based on the underlying etiology. For example, when an intracranial abscess is believed to be due to extension of infection from paranasal sinuses involving staphylococcal, aerobic, and anaerobic bacteria, more than one antibiotic is necessary. Similarly, an antistaphylococcal agent is an appropriate choice for infection occurring after a neurosurgical procedure.



Class Summary

For patients presenting in the ED with intracranial epidural abscess, empiric antibiotics are the first-line pharmacologic therapy. These antibiotics must cover a broad spectrum of both aerobic and anaerobic bacterial organisms.

Penicillin G (Pfizerpen)


Along with chloramphenicol, constitutes first-line regimen for empiric treatment of intracranial epidural abscess in the ED. Provides coverage for anaerobes and streptococci.

Chloramphenicol (Chloromycetin)


Constitutes the other half of classic first-line empiric regimen. Enhances anaerobic coverage to include Bacteroides fragilis, Enterobacteriaceae, and Haemophilus species infections.

Cefotaxime (Claforan)


In combination with metronidazole, can replace penicillin G and chloramphenicol. In this regimen, cefotaxime covers streptococci, staphylococci, Haemophilus species, and Enterobacteriaceae. Third-generation cephalosporin with broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more of the penicillin-binding proteins.

Metronidazole (Metro IV Injection)


Second half of alternative regimen to penicillin/chloramphenicol. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Has proved especially effective in otogenic intracranial epidural abscesses.

Nafcillin (Unipen)


Should be added to either regimen mentioned above if S aureus is strongly suspected. Treats infections caused by penicillinase-producing staphylococci. Used to initiate therapy when patients are suspected of having penicillin G resistant staphylococcal infection. Do not use for treatment of penicillin G susceptible staphylococci. Use parenteral therapy initially in severe infections. Very severe infections may require very high doses. Change to PO therapy as condition improves. Because of occasional occurrence of thrombophlebitis associated with parenteral route (particularly in elderly individuals), administer parenterally only for a short period (24-48 h) and change to PO route if clinically possible.

Vancomycin (Vancocin, Lyphocin)


Replaces nafcillin in patients who are allergic to penicillin and in patients who are suspected to have MRSA as an etiologic agent. Potent antibiotic directed against gram-positive organisms and active against enterococci species. Also useful in treating septicemia and skin structure infections.

Ceftazidime (Fortaz, Ceptaz)


Should be added to empiric regimens if pseudomonads are suspected. Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more of the penicillin-binding proteins.



Class Summary

Anti-inflammatory effects of steroid therapy can decrease associated cerebral edema, reducing ICP. These benefits are offset somewhat by the fact that steroid use decreases antibiotic penetration into the abscess and may slow encapsulation of the abscess site.

Dexamethasone (Decadron, Dexasone)


Corticosteroid of choice for reducing ICP. Used in treatment of inflammatory diseases. May decrease inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Contributor Information and Disclosures

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS is a member of the following medical societies: American College of International Physicians, American Heart Association, American Stroke Association, American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.


Arun Ramachandran, MD State University of New York Upstate Medical University

Arun Ramachandran, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Florian P Thomas, MD, PhD, Drmed, MA, MS Director, National MS Society Multiple Sclerosis Center; Professor and Director, Clinical Research Unit, Department of Neurology, Adjunct Professor of Physical Therapy, Associate Professor, Institute for Molecular Virology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, Drmed, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MD, DM Associate Professor of Neurology, University of Missouri-Columbia School of Medicine

Niranjan N Singh, MD, DM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Additional Contributors

Ramon Diaz-Arrastia, MD, PhD Professor, Department of Neurology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Director, North Texas TBI Research Center, Comprehensive Epilepsy Center, Parkland Memorial Hospital

Ramon Diaz-Arrastia, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, New York Academy of Sciences, Phi Beta Kappa

Disclosure: Nothing to disclose.

  1. Bleck TP, Greenlee JE. Mandell GL, et al. Principles and Practice of Infectious Diseases. New York: Churchill Livingstone; 2000. 1028-1031.

  2. Yildirmak T, Gedik H, Simsek F, Kantürk A. Community-acquired intracranial suppurative infections: A 15-year report. Surg Neurol Int. 2014. 5:142. [Medline]. [Full Text].

  3. Britton CB. Infections of the nervous system complicating alcoholism and illicit drug use. Continuum: Lifelong Learning in Neurology. 2004 Oct. 5:48-76.

  4. Erman T, Demirhindi H, Göçer AI, Tuna M, Ildan F, Boyar B. Risk factors for surgical site infections in neurosurgery patients with antibiotic prophylaxis. Surg Neurol. 2005 Feb. 63(2):107-12; discussion 112-3. [Medline].

  5. Korinek AM, Golmard JL, Elcheick A, Bismuth R, van Effenterre R, Coriat P. Risk factors for neurosurgical site infections after craniotomy: a critical reappraisal of antibiotic prophylaxis on 4,578 patients. Br J Neurosurg. 2005 Apr. 19(2):155-62. [Medline].

  6. Harris LF, Haws FP, Triplett JN Jr, Maccubbin DA. Subdural empyema and epidural abscess: recent experience in a community hospital. South Med J. 1987 Oct. 80(10):1254-8. [Medline].

  7. Germiller JA, Monin DL, Sparano AM, Tom LW. Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg. 2006 Sep. 132(9):969-76. [Medline].

  8. Woods CR Jr. Brain abscess and other intracranial suppurative complications. Adv Pediatr Infect Dis. 1995. 10:41-79. [Medline].

  9. Mittal MK, Zimmerman RA. Meningitis and epidural abscess related to pansinusitis. Pediatr Emerg Care. 2009 Apr. 25(4):267-8. [Medline].

  10. Seto T, Takesada H, Matsushita N, Ishibashi K, Tsuyuguchi N, Shimono T, et al. Twelve-year-old girl with intracranial epidural abscess and sphenoiditis. Brain Dev. 2014 Apr. 36(4):359-61. [Medline].

  11. Mallur PS, Harirchian S, Lalwani AK. Preoperative and postoperative intracranial complications of acute mastoiditis. Ann Otol Rhinol Laryngol. 2009 Feb. 118(2):118-23. [Medline].

  12. Kraus M, Shelef I, Niv A, Kaplan DM. The vein of Labbe masquerading as an epidural abscess. J Laryngol Otol. 2007 Aug. 121(8):e12. [Medline].

  13. Noggle JC, Sciubba DM, Nelson C, Garcés-Ambrossi GL, Ahn E, Jallo GI. Supraciliary keyhole craniotomy for brain abscess debridement. Neurosurg Focus. 2008. 24(6):E11. [Medline].

  14. Eviatar E, Lavi R, Fridental I, Gavriel H. Endonasal endoscopic drainage of frontal lobe epidural abscess. Isr Med Assoc J. 2008 Mar. 10(3):239-40. [Medline].

  15. Pradilla G, Ardila GP, Hsu W, Rigamonti D. Epidural abscesses of the CNS. Lancet Neurol. 2009 Mar. 8(3):292-300. [Medline].

  16. Akova M, Akalin HE, Korten V, et al. Treatment of intracranial abscesses: experience with sulbactam/ampicillin. J Chemother. 1993 Jun. 5(3):181-5. [Medline].

  17. Ariza J, Casanova A, Fernandez Viladrich P, et al. Etiological agent and primary source of infection in 42 cases of focal intracranial suppuration. J Clin Microbiol. 1986 Nov. 24(5):899-902. [Medline].

  18. Bizakis JG, Velegrakis GA, Papadakis CE, et al. The silent epidural abscess as a complication of acute otitis media in children. Int J Pediatr Otorhinolaryngol. 1998 Oct 2. 45(2):163-6. [Medline].

  19. Brook I, Friedman EM. Intracranial complications of sinusitis in children. A sequela of periapical abscess. Ann Otol Rhinol Laryngol. 1982 Jan-Feb. 91(1 Pt 1):41-3. [Medline].

  20. Cohen AR, Gupta N. Mass in the forehead of a three-year-old girl. Pediatr Neurosurg. 2002 Jul. 37(1):38-47. [Medline].

  21. Coyne TJ, Kemp RJ. Intracranial epidural abscess: a report of three cases. Aust N Z J Surg. 1993 Feb. 63(2):154-7. [Medline].

  22. Daniels LK. Rapid in-office and in-vivo desensitization of an injection phobia utilizing hypnosis. Am J Clin Hypn. 1976 Jan. 18(3):200-3. [Medline].

  23. Durand B, Poje C, Dias M. Sinusitis-associated epidural abscess presenting as posterior scalp abscess--a case report. Int J Pediatr Otorhinolaryngol. 1998 Mar 1. 43(2):147-51. [Medline].

  24. Efird T, Ram S, Neitzschman HR. Radiology case of the month. Chronic headache after trauma. Intracranial epidural abscess. J La State Med Soc. 2004 Jan-Feb. 156(1):12-4. [Medline].

  25. Fountas KN, Duwayri Y, Kapsalaki E, et al. Epidural intracranial abscess as a complication of frontal sinusitis: case report and review of the literature. South Med J. 2004 Mar. 97(3):279-82; quiz 283. [Medline].

  26. Gallagher RM, Gross CW, Phillips CD. Suppurative intracranial complications of sinusitis. Laryngoscope. 1998 Nov. 108(11 Pt 1):1635-42. [Medline].

  27. Gil-Carcedo LM, Izquierdo JM, Gonzalez M. Intracranial complications of frontal sinusitis. A report of two cases. J Laryngol Otol. 1984 Sep. 98(9):941-5. [Medline].

  28. Gower D, McGuirt WF. Intracranial complications of acute and chronic infectious ear disease: a problem still with us. Laryngoscope. 1983 Aug. 93(8):1028-33. [Medline].

  29. Green HT, O'Donoghue MA, Shaw MD, Dowling C. Penetration of ceftazidime into intracranial abscess. J Antimicrob Chemother. 1989 Sep. 24(3):431-6. [Medline].

  30. Harrison MJ. The clinical presentation of intracranial abscesses. Q J Med. 1982. 51(204):461-8. [Medline].

  31. Hirschberg H, Bosnes V. C-reactive protein levels in the differential diagnosis of brain abscesses. J Neurosurg. 1987 Sep. 67(3):358-60. [Medline].

  32. Hlavin ML, Kaminski HJ, Fenstermaker RA, White RJ. Intracranial suppuration: a modern decade of postoperative subdural empyema and epidural abscess. Neurosurgery. 1994 Jun. 34(6):974-80; discussion 980-1. [Medline].

  33. Ildan F, Gursoy F, Gul B, et al. Intracranial tuberculous abscess mimicking malignant glioma. Neurosurg Rev. 1994. 17(4):317-20. [Medline].

  34. Johnson DL, Markle BM, Wiedermann BL, Hanahan L. Treatment of intracranial abscesses associated with sinusitis in children and adolescents. J Pediatr. 1988 Jul. 113(1 Pt 1):15-23. [Medline].

  35. Kamiya K, Inagawa T. Huge calcified epidural abscess--case report. Neurol Med Chir (Tokyo). 1990 Jul. 30(7):495-7. [Medline].

  36. Kaufman DM, Leeds NE. Computed tomography (CT) in the diagnosis of intracranial abscesses. Brain abscess, subdural empyema, and epidural empyema. Neurology. 1977 Nov. 27(11):1069-73. [Medline].

  37. Lefkowitz MA, Chin LS, Couldwell WT. Pediatric intracranial epidural abscess secondary to an infected scalp vein catheter. Pediatr Neurosurg. 1998 Dec. 29(6):297-9. [Medline].

  38. Lerner DN, Choi SS, Zalzal GH, Johnson DL. Intracranial complications of sinusitis in childhood. Ann Otol Rhinol Laryngol. 1995 Apr. 104(4 Pt 1):288-93. [Medline].

  39. Letscher V, Herbrecht R, Gaudias J, et al. Post-traumatic intracranial epidural Aspergillus fumigatus abscess. J Med Vet Mycol. 1997 Jul-Aug. 35(4):279-82. [Medline].

  40. Mammen-Prasad E, Murillo JL, Titelbaum JA. Infectious disease rounds: Pott's puffy tumor with intracranial complications. N J Med. 1992 Jul. 89(7):537-9. [Medline].

  41. Miller ES, Dias PS, Uttley D. CT scanning in the management of intracranial abscess: a review of 100 cases. Br J Neurosurg. 1988. 2(4):439-46. [Medline].

  42. Morioka T, Fujiwara S, Akimoto T, et al. Intracranial epidural abscess: late complication of allograft cranioplasty. Fukuoka Igaku Zasshi. 1996 Feb. 87(2):57-9. [Medline].

  43. Nathoo N, Nadvi SS, van Dellen JR. Cranial extradural empyema in the era of computed tomography: a review of 82 cases. Neurosurgery. 1999 Apr. 44(4):748-53; discussion 753-4. [Medline].

  44. Norrell HA Jr, Wilson CB. Primary intracranial extradural abscess diagnosed by carotid angiography. J Ky Med Assoc. 1967 Dec. 65(12):1186-87+. [Medline].

  45. Papo I, Perria C, Carai M, et al. The surgical treatment of intracranial abscesses today. Zentralbl Neurochir. 1989. 50(1):34-8. [Medline].

  46. Parker GS, Tami TA, Wilson JF, Fetter TW. Intracranial complications of sinusitis. South Med J. 1989 May. 82(5):563-9. [Medline].

  47. Pascual J, Diez C, Carda JR, Vazquez-Barquero A. Intraventricular haemorrhage complicating a brain abscess. Postgrad Med J. 1987 Sep. 63(743):785-7. [Medline].

  48. Rath SA, Knoringer P. Late brain abscess years after severe cerebrocranial trauma with fronto-orbitobasal fracture. Childs Nerv Syst. 1989 Apr. 5(2):121-3. [Medline].

  49. Reader ME, Eliachar I, McIntire LD, Hahn J. Frontal sinusitis with chronic epidural abscess: a case presentation. Ear Nose Throat J. 1992 Nov. 71(11):599-603. [Medline].

  50. Rosenfeld EA, Rowley AH. Infectious intracranial complications of sinusitis, other than meningitis, in children: 12-year review. Clin Infect Dis. 1994 May. 18(5):750-4. [Medline].

  51. Savitz MH, Dickinson T. Drug therapy for intracranial suppuration. Am Fam Physician. 1988 Feb. 37(2):341-4. [Medline].

  52. Schliamser SE, Backman K, Norrby SR. Intracranial abscesses in adults: an analysis of 54 consecutive cases. Scand J Infect Dis. 1988. 20(1):1-9. [Medline].

  53. Sellick JA Jr. Epidural abscess and subdural empyema. J Am Osteopath Assoc. 1989 Jun. 89(6):806-10. [Medline].

  54. Sharif HS, Ibrahim A. Intracranial epidural abscess. Br J Radiol. 1982 Jan. 55(649):81-4. [Medline].

  55. Smith HP, Hendrick EB. Subdural empyema and epidural abscess in children. J Neurosurg. 1983 Mar. 58(3):392-7. [Medline].

  56. Weiner GM, Williams B. Prevention of intracranial problems in ear and sinus surgery: a possible role for cefotaxime. J Laryngol Otol. 1993 Nov. 107(11):1005-7. [Medline].

  57. Weingarten K, Zimmerman RD, Becker RD, et al. Subdural and epidural empyemas: MR imaging. AJR Am J Roentgenol. 1989 Mar. 152(3):615-21. [Medline].

  58. Wenig BL, Goldstein MN, Abramson AL. Frontal sinusitis and its intracranial complications. Int J Pediatr Otorhinolaryngol. 1983 Jul. 5(3):285-302. [Medline].

  59. Woods CR Jr. Brain abscess and other intracranial suppurative complications. Adv Pediatr Infect Dis. 1995. 10:41-79. [Medline].

CT scan showing lenticular-shaped intracranial epidural abscess.
Intracranial epidural abscess. Enhanced MRI of the brain, axial section, revealing a left temporal epidural abscess with an abscess cavity and a thickened enhancing capsule. Adjacent thickened dura enhances as well. In addition, mass effect is evident.
Intracranial epidural abscess. A coronal section of the MRI revealing a left temporal epidural abscess with an abscess cavity and a thickened enhancing capsule. Adjacent thickened dura enhances as well. In addition, mass effect is evident.
Intracranial epidural abscess. MRI of the brain, unenhanced. A T1-weighted image (axial view) showing a left temporal epidural abscess with an abscess cavity, surrounding capsule, and the thickened dura underneath. Mass effect is evident.
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