eMedicine Specialties > Neurology > Neurological Infections

Intracranial Epidural Abscess: Treatment & Medication

Author: Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Coauthor(s): Arun Ramachandran, State University of New York Upstate Medical University
Contributor Information and Disclosures

Updated: Sep 9, 2009

Treatment

Medical Care

Early diagnosis and treatment of epidural abscess cannot be overemphasized as neurologic outcome mainly depends on the patient’s neurologic status immediately prior to surgery.

  • Prehospital management
    • Rapid transport and early stabilization are highly essential in the prehospital setting.
    • Endotracheal intubation and hyperventilation may be required in some patients who are critically ill.
  • Initial management (depends upon the type of clinical presentation)
    • The presence of seizures and focal neurological deficits requires emergent intubation, anticonvulsant therapy, hyperventilation, and hemodynamic stabilization before proceeding with diagnostic tests.
    • Patients who are not critically ill or who have a subtle presentation may undergo CT scanning after initial clinical evaluation. Neurologic status should be monitored closely.
  • Antibiotic therapy
    • Until the culture and sensitivity report of the infectious agent becomes available, the choice of empiric antibiotic therapy should be based on the underlying etiology. For example, when an intracranial abscess is thought to be due to extension of infection from paranasal sinuses involving staphylococcal, aerobic, and anaerobic bacteria, more than one antibiotic is necessary. Likewise, an antistaphylococcal agent would be an appropriate choice for infection occurring after a neurosurgical procedure.
    • For patients presenting in the emergency department (ED) with cranial epidural abscess, empirical antibiotics are the first-line pharmacologic therapy. These antibiotics must cover a broad spectrum of both aerobic and anaerobic bacterial organisms.
    • Usually, length of therapy is determined by the patient's response to treatment and by resolution of the epidural abscess on follow-up MRI and/or CT scanning. As a general rule, antibiotic therapy should be continued for a minimum of 8 weeks if surgery is not undertaken and for at least 4 weeks if the abscess is drained. Antibiotics have been administered from 6 weeks to 6 months. In general, follow-up CT scanning or MRI should be obtained 10-14 days after antibiotic therapy has been discontinued.
  • Seizure therapy
    • Prophylactic seizure therapy is not generally recommended. If cranial epidural abscess is not associated with subdural empyema, seizures are unlikely to ensue. In the event of the administration of anticonvulsant therapy, consider weaning patients off anticonvulsant therapy if patients remain seizure free for more than 2 years and the EEG findings do not show any evidence of seizure disorder.
    • Discontinuing anticonvulsant therapy suddenly can be risky because it can lead to recurrent seizures, which may be prolonged. This is true even if the medication was not successfully controlling the seizures. Weaning patients off the drug gradually after fully understanding the potential possibility of recurrent seizure(s) and related consequences, including losing a driving license and the possible impact on employment, is strongly advised. If seizures do recur, resuming the previous medication immediately usually results in the same level of seizure control as before. However, in rare instances, the original antiepileptic medication may not be as effective, even if previously successful; alternative therapy should be considered.

Surgical Care

Surgical intervention is an integral part of treatment for epidural abscesses in patients with neurologic symptoms or who have not responded to medical management.

  • Optimal management of an intracranial epidural abscess should include neurosurgical drainage; Gram stain, India ink, and acid-fast bacilli (AFB) staining of the purulent material; and administration of appropriate intravenous antibiotic(s). In case of small abscesses, adequate appropriate antibiotic therapy alone might suffice, without the need for surgical intervention.
  • The goal of therapy is to eradicate the infection and prevent further complications. Surgical exploration, decompression, and debridement, along with antibiotic therapy, are the mainstays of surgical treatment in cranial epidural abscess.
  • The type of emergency surgery for cranial epidural abscess depends on the extent of the lesion and involvement of the overlying skull bone.
    • When burr holes cannot provide sufficient drainage or when debridement with drainage is indicated, craniotomy is undertaken.
    • When the dura is affected by infection, a dural graft may be required. During anesthesia, anesthetics that can cause intracranial vasodilation should be avoided because this might result in further increase in intracranial pressure, heralding herniation.
  • Noggle et al report that frontal, supraorbital epidural abscesses of the anterior and middle cranial fossa can be adequately and safely debrided via a minimally invasive supraciliary craniotomy. This approach has a cosmetic benefit and may decrease approach-related morbidity.11
  • Eviator et al recommend that in cases of epidural abscess secondary to sinusitis that are located in the anterior base of the skull, draining the abscess endoscopically via nasal space may be considered by an experienced surgeon. This is minimally invasive, particularly so when osteomyelitis and other anatomical abnormalities of the skull exist.12

Consultations

  • Immediate neurosurgical consultation is highly warranted.
  • A multidisciplinary approach involving an otolaryngologist may be necessary if the patient presents with concurrent paranasal sinusitis.

Medication

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.

Antibiotics

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.

Adult

6 million U IV q6h

Pediatric

<14 kg (30 lb): 600,000 U IV q6h
14-27 kg (30-60 lb): 900,000-1,200,000 U IV q6h

Probenecid can increase penicillin effectiveness by decreasing its clearance; concurrent administration of tetracycline can decrease effects of penicillin

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in patients with impaired renal function


Chloramphenicol (Chloromycetin)

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

Adult

4-6 g/d IV

Pediatric

Not established

When taken concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase, resulting in increased toxicity; clinical manifestations of hypoglycemia may occur when taken concurrently with sulfonylureas; concomitant administration with rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; concurrent administration of anticoagulants may increase effects of anticoagulants; serum hydantoin levels may be increased, possibly resulting in toxicity; in addition, chloramphenicol levels may be increased or decreased

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Must not be used to treat trivial infections other than those indicated or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and periodic blood studies approximately q2d during therapy; discontinue if reticulocytopenia, leukopenia, thrombocytopenia, anemia, or any other findings attributable to chloramphenicol appear; recommended dose in patients with impaired liver or kidney function may result in toxic drug levels; exercise caution during pregnancy at term or during labor because of potential toxic effects to fetus (Gray syndrome)


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.

Adult

12 g/d IV

Pediatric

Neonates > 1 week: 50 mg/kg IV q12h
Neonates 1-4 weeks: 50 mg/kg IV q18h
Infants and children: 50-100 mg/kg IV/IM q6h or q8h

Probenecid may decrease cefotaxime clearance, causing increase in cefotaxime levels; furosemide and aminoglycosides may increase nephrotoxicity when used concurrently with cefotaxime

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in patients diagnosed with severe renal impairment; has been associated with severe colitis


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.

Adult

400-600 mg IV q6h

Pediatric

Not established

Potentiates anticoagulant effect of warfarin; agents that alter hepatic P450 system also affect its clearance; phenytoin and phenobarbital may decrease half-life of metronidazole; cimetidine may reduce metronidazole clearance and increase its toxicity; metronidazole may increase effect of anticoagulants and may decrease lithium and phenytoin clearance, increasing their toxicity; disulfiramlike reaction may occur when used concurrently with PO ingested ethanol; although risk for most patients may be slight, caution is advised

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in patients with severe hepatic disease because they may metabolize metronidazole slowly; monitor patients for seizures and peripheral neuropathy


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.

Adult

12-18 g/d IV

Pediatric

Not established

Has been associated with warfarin resistance when administered concurrently; bacteriostatic action of tetracycline derivatives may impair bactericidal effects of penicillin

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform bacteriologic studies to determine causative organisms and their susceptibility so that appropriate therapy is administered; therapy duration must be sufficient to eliminate organism (minimum 10 d), otherwise sequelae (eg, endocarditis, rheumatic fever) may ensue; take cultures after treatment to confirm that streptococci are eradicated


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.

Adult

15 mg/kg IV q8-12h

Pediatric

Not established

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; when taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that associated with aminoglycoside alone; effects on neuromuscular blockade may be enhanced when used concurrently with nondepolarizing muscle relaxants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with renal failure or neutropenia; adjust dose as needed in patients diagnosed with renal impairment; red man syndrome is caused by a too-rapid IV infusion (dose administered over a few min) but rarely happens when dose is administered as 2-h administration or as PO or intraperitoneal administration; red man syndrome is not an allergic reaction; monitor for ototoxicity


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.

Adult

6 g/d IV

Pediatric

Not established

Aminoglycosides, furosemide, and ethacrynic acid increase nephrotoxic potential; probenecid may decrease ceftazidime clearance, causing increase in ceftazidime levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in patients diagnosed with renal impairment

Corticosteroids

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.

Adult

10-12 mg IV loading dose, followed by 4 mg IV q6h

Pediatric

Loading dose: 1-2 mg/kg/dose IV once
Follow-up maintenance dose: 1-1.5 mg/kg/d IV; not to exceed 16 mg/d divided q4-6h for 5 d; taper dose for 5 d and discontinue use

May decrease antibiotic penetration in abscesses; use of barbiturates, phenytoin, and rifampin can decrease dexamethasone effects; decreases effects of salicylates and vaccines used for immunization

Documented hypersensitivity; untreated active infection; fungal infection

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor for adrenal insufficiency when tapering drug; patients receiving glucocorticoids are at risk of multiple complications including severe infections; abrupt discontinuation may cause an adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

More on Intracranial Epidural Abscess

Overview: Intracranial Epidural Abscess
Differential Diagnoses & Workup: Intracranial Epidural Abscess
Treatment & Medication: Intracranial Epidural Abscess
Follow-up: Intracranial Epidural Abscess
Multimedia: Intracranial Epidural Abscess
References
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Further Reading

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Keywords

epidural abscess, cranial epidural abscess, CEA, epidural empyema, patchy meningitis externa, increased intracranial pressure, ICP, intracranial infection, infection of the epidural space, epidural space infection

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Contributor Information and Disclosures

Author

Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Abbott Labs  Honoraria Consulting; Teva Marion Honoraria Consulting; Boeringer-Ingelheim Honoraria Speaking and teaching

Coauthor(s)

Arun Ramachandran, State University of New York Upstate Medical University
Arun Ramachandran is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ramon Diaz-Arrastia, MD, PhD, Assistant Professor, Department of Neurology, Comprehensive Epilepsy Center, University of Texas Southwestern
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, and Phi Beta Kappa
Disclosure: Nothing to disclose.

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Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
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