eMedicine Specialties > Neurology > Neurological Infections
Spinal Epidural Abscess: Treatment & Medication
Updated: Aug 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Treatment consists of both medical10 and surgical therapy.
- Empiric antibiotic coverage should include antistaphylococcal antibiotics. With the increasing incidence of methicillin-resistant staphylococcal infections, coverage that includes medications effective against MRSA is recommended. If the infection follows a neurosurgical procedure, an antistaphylococcal penicillin, a third-generation cephalosporin, and an aminoglycoside are prescribed in combination. Culture results guide definitive therapy.
- Resolution with antibiotics alone has been reported in patients who are not candidates for surgery because of spine instability or coexisting medical problems. Medical treatment with or without aspiration of the epidural space is increasingly used in patients without neurologic deficits.
- Deterioration of clinical and functional status while undergoing antibiotic therapy alone has been observed and may dictate emergency surgical decompression.
- Because of the rarity of the disorder, no randomized trial results are available to guide the clinician.
Surgical Care
- Emergency surgical decompression of the spinal cord and drainage of the abscess is the usual surgical treatment.11
- Increasing neurologic deficit, persistent severe pain, or persistent fever and leukocytosis are all indications for surgery.
- Successful treatment with a combination of abscess aspiration and antibiotic treatment has been reported.
- Patients with spinal epidural abscess may be clinically unstable because of concomitant systemic infection, shock, complications of diabetes mellitus, or other complications. As a result, an increased surgical risk often must be weighed in the decision process.
Consultations
- Consultation with a spine surgeon should be requested when spinal epidural abscess is detected or strongly suspected.
- Consultation with an infectious disease specialist may be helpful in the selection of antibiotics and combinations.
Medication
Antibiotic treatment should be initiated as soon as possible and in conjunction with surgical therapy. The usual duration of the therapy is 3-4 weeks, but it may be prolonged in the presence of osteomyelitis.
Antibiotics
Because S aureus is a common pathogen, antistaphylococcal drugs should be included in the treatment regimen. An antistaphylococcal penicillin, a cephalosporin, or vancomycin may be used. If the patient has undergone a neurosurgical procedure recently, the penicillin should be combined with a third-generation cephalosporin and an aminoglycoside. Gram-stain and culture results are used to guide therapy.
Ceftriaxone (Rocephin)
Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult
2 g IV q12-24h
Pediatric
Not established
Probenecid may decrease clearance and increase serum levels; ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
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 renal impairment and use with caution in breastfeeding women and patients allergic to penicillin
Nafcillin (Unipen)
Treats infections caused by penicillinase-producing staphylococci. Used to initiate therapy in any patient in whom penicillin G-resistant staphylococcal infection suspected. Should not be used for treatment of penicillin G-susceptible staphylococci.
Parenteral therapy used initially in severe infections. Very severe infections may require very high doses. As condition improves, parenteral therapy should be changed to oral therapy.
Because of occasional occurrence of thrombophlebitis associated with parenteral route, particularly in the elderly, parenteral route should be used only for short term (24-48 h) and changed to oral route, if clinically possible.
Adult
2 g IV q4h
Pediatric
37.5 mg/kg IV q6h
Associated with warfarin resistance; bacteriostatic action of tetracycline derivatives may impair bactericidal effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bacteriologic studies should be performed to determine causative organisms and their susceptibility so that appropriate therapy administered; duration of therapy must be sufficient to eliminate organism (minimum of 10 d), otherwise sequelae (eg, endocarditis, rheumatic fever) may ensue
Cultures should be taken after treatment to confirm eradication of pathogens
Cefazolin (Ancef, Kefzol, Zolicef)
First-generation semisynthetic cephalosporin, which by binding to penicillin-binding proteins arrests bacterial cell wall synthesis and inhibits bacterial growth. Active primarily against skin flora, including S aureus. Total daily dosage is same for both IV and IM routes.
Adult
2 g IV q8h
Pediatric
20 mg/kg IV/IM q8-12h
Probenecid decreases renal clearance and prolongs effect; aminoglycosides may increase renal toxicity; may yield false-positive urine dip for glucose
Documented hypersensitivity
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 renal impairment; prolonged use of antibiotics associated with superinfections and promotion of nonsusceptible organisms—however, complications usually reversible
Metronidazole (Flagyl)
Used in combination with other antibiotics in epidural abscess following neurosurgical procedures. Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells, and intermediate-metabolized compounds formed bind DNA and inhibit protein synthesis, causing cell death.
Adult
500 mg IV q6-12h
Pediatric
15 mg/kg IV q12h
Potentiates anticoagulant effect of warfarin; agents that alter hepatic P450 system also affect clearance—phenytoin and phenobarbital may decrease half-life; orally ingested ethanol may cause disulfiramlike reaction—although risk for most patients is slight, caution advised
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid in patients with hypersensitivity to parabens; adjust dose in patients with severe hepatic disease since they may metabolize drug slowly; monitor patients for seizures and development of peripheral neuropathy
Gentamicin (Gentacidin, Garamycin)
Used in combination with other antibiotics for epidural abscess following neurosurgical procedures. Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution. May be administered IV or IM.
Adult
1.5 mg/kg IV q8h
May adjust dosage in patients with renal impairment
Pediatric
Neonates and infants: 7.5 mg/kg/d IV
Children: 6-7.5 mg/kg/d IV
Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxic potential; enhances effects of neuromuscular blocking agents, which may result in prolonged respiratory depression
Loop diuretics appear to increase auditory toxicity—hearing loss of varying degrees may occur and may be irreversible; important to monitor patients regularly
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
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
Due to narrow therapeutic index and toxicity associated with extended administration, not intended for long-term therapy
Adjust dose in patients with renal impairment; improper dosing (without regard to serum levels) may lead to ototoxicity or nephrotoxicity; use caution in patients with renal failure (not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission
Vancomycin (Vancocin)
Often used when MRSA or other resistant organisms are suspected. Potent antibiotic directed against gram-positive organisms and active against enterococci species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or whose conditions have failed to respond to penicillins and cephalosporins, or those who have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.
Adult
500 mg to 2 g/d IV divided tid/qid 7-10 d
Pediatric
40 mg/kg/d IV divided tid/qid 7-10 d
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
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 renal failure and neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
More on Spinal Epidural Abscess |
| Overview: Spinal Epidural Abscess |
| Differential Diagnoses & Workup: Spinal Epidural Abscess |
 Treatment & Medication: Spinal Epidural Abscess |
| Follow-up: Spinal Epidural Abscess |
| Multimedia: Spinal Epidural Abscess |
| References |
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References
Darouiche RO. Spinal epidural abscess. N Engl J Med. Nov 9 2006;355(19):2012-20. [Medline].
Bremer AA, Darouiche RO. Spinal epidural abscess presenting as intra-abdominal pathology: a case report and literature review. J Emerg Med. Jan 2004;26(1):51-6. [Medline].
Rigamonti D, Liem L, Sampath P, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol. Aug 1999;52(2):189-96; discussion 197. [Medline].
Joshi SM, Hatfield RH, Martin J, Taylor W. Spinal epidural abscess: a diagnostic challenge. Br J Neurosurg. Apr 2003;17(2):160-3. [Medline].
Prendergast H, Jerrard D, O'Connell J. Atypical presentations of epidural abscess in intravenous drug abusers. Am J Emerg Med. Mar 1997;15(2):158-60. [Medline].
Davis DP, Wold RM, Patel RJ, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med. Apr 2004;26(3):285-91. [Medline].
Trombly R, Guest JD. Acute central cord syndrome arising from a cervical epidural abscess: case report. Neurosurgery. Aug 2007;61(2):E424-5; discussion E425. [Medline].
Tasher D, Armarnik E, Mizrahi A, Liat BS, Constantini S, Grisaru-Soen G. Cat Scratch Disease With Cervical Vertebral Osteomyelitis and Spinal Epidural Abscess. Pediatr Infect Dis J. Jul 31 2009;[Medline].
Mehta SH, Shih R. Cervical epidural abscess associated with massively elevated erythrocyte sedimentation rate. J Emerg Med. Jan 2004;26(1):107-9. [Medline].
Siddiq F, Chowfin A, Tight R, et al. Medical vs surgical management of spinal epidural abscess. Arch Intern Med. Dec 13-27 2004;164(22):2409-12. [Medline].
Pereira CE, Lynch JC. Spinal epidural abscess: an analysis of 24 cases. Surg Neurol. 2005;63 Suppl 1:S26-9. [Medline].
Bluman EM, Palumbo MA, Lucas PR. Spinal epidural abscess in adults. J Am Acad Orthop Surg. May-Jun 2004;12(3):155-63. [Medline].
Butler KH. Spinal epidural abscess: Current diagnostic and management protocols. Emerg Med Rep. 21:95-104.
Gerberding JL, Romero JM, Ferraro MJ. Case records of the Massachusetts General Hospital. Case 34-2008. A 58-year-old woman with neck pain and fever. N Engl J Med. Oct 30 2008;359(18):1942-9. [Medline].
Grewal S, Hocking G, Wildsmith JA. Epidural abscesses. Br J Anaesth. Mar 2006;96(3):292-302. [Medline].
Hooten WM, Kinney MO, Huntoon MA. Epidural abscess and meningitis after epidural corticosteroid injection. Mayo Clin Proc. May 2004;79(5):682-6. [Medline].
Tessman PA, Preston DC, Shapiro BE. Spinal epidural abscess in an afebrile patient. Arch Neurol. Apr 2004;61(4):590-1. [Medline].
Uchida K, Nakajima H, Yayama T, Sato R, Kobayashi S, Chen KB, et al. Epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine; evaluation of a new MRI staging classification and imaging findings as indicators of surgical management: a retrospective study of 37 patients. Arch Orthop Trauma Surg. Jun 30 2009;[Medline].
Further Reading
Keywords
spinal cord compression, vertebral osteomyelitis, epidural space infection, Staphylococcus aureus, Staphylococcus species, Pseudomonas species, Escherichia coli, Mycobacterium tuberculosis, brucellosis, spinal cord dysfunction, localized spinal pain, radicular pain and paresthesias, muscular weakness, sensory loss, sphincter dysfunction, paralysis
