eMedicine Specialties > Neurology > Neurological Infections
Subdural Empyema: Treatment & Medication
Updated: Mar 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Prehospital care: Maintain an adequate airway and ensure breathing and circulation by supportive care (eg, oxygen). Establish an intravenous line with adequate monitoring while en route to the emergency department.
- Emergency department care: Continue supportive treatment (ie, ABCs) directed toward stabilizing the patient.
- Request necessary imaging studies and laboratory tests.
- Commence antibiotic therapy as soon as possible with broad coverage for anaerobes, staphylococci, and aerobic streptococci.
- The neurosurgical team should be involved; thoracic surgery and otolaryngology teams also should be consulted if necessary.
- Antibiotic therapy4 alone may be adequate for small subdural empyema (ie, <1.5 cm diameter). Because of the aggressive nature of this disease, however, this option is not widely utilized. This is an option for patients with major contraindications to surgery or significant mortality risks.
- Other medical interventions may include medications for seizure treatment or prophylaxis. Treatment for increased intracranial pressure also has been advocated.
Surgical Care
- Immediate neurosurgical drainage5 of the subdural empyema should be considered.
- The primary surgical option is craniotomy, which allows wide exposure, adequate exploration, and better evacuation of the purulent collection than other procedures.
- Stereotatic burr hole placement with drainage and irrigation is another option but is less desirable because of decreased exposure and possible incomplete evacuation of the purulent material.
- Drainage and debridement of the primary source of infection may be necessary.
- Samples should be collected for Gram staining, culture, and sensitivity tests.
- Patients with contraindications to surgery or significant mortality risks may receive antibiotic therapy alone.6
- Other surgical interventions may be required to debride or evacuate the primary source of infection. Such efforts may require an otolaryngologist for paranasal sinusitis (eg, bilateral antral washout, mastoidectomy for recurrent chronic mastoiditis, grommets for recurrent otitis media) or a thoracic surgeon for a chronic lung abscess.
Consultations
- Neurosurgery, otolaryngology, and thoracic surgery consultations
- Physical medicine and rehabilitation for physical therapy, gait and balance training, occupational therapy, and speech therapy
- Clinical psychologist for treatment of any residual cognitive deficit
- Ophthalmology or optometry consult if a visual defect is present, especially in patients with palsies of cranial nerves III, V, or VI, or visual field defects (eg, homonymous hemianopsia)
- Home care aides and social work for issues after discharge (About 55% of patients have neurological deficits on discharge.)
Activity
Maintaining balance and gait training is important; patients should be assessed and treated in conjunction with the rehabilitation department.
Medication
The goal of pharmacotherapy is to reduce morbidity and prevent complications.
Antibiotics
Appropriate antibiotics always should be given in addition to any surgical intervention. While awaiting the results of the Gram stain and culture and sensitivities, empirical antibiotic therapy should be instituted against anaerobes, aerobic streptococci, and staphylococci. The antibiotics should be given for a period of 3-6 wk with close monitoring of clinical status.
Paranasal sinusitis - Beta-lactamase-stable penicillin + metronidazole + third-generation cephalosporin (except cefoperazone)
Otitis media, mastoiditis - Beta-lactamase-stable penicillin + metronidazole + third-generation cephalosporin (except cefoperazone)
Trauma, postsurgical infection - Vancomycin + third-generation cephalosporin (except cefoperazone)
Pulmonary spread - Beta-lactamase-stable penicillin + metronidazole + third-generation cephalosporin (except cefoperazone)
Meningitis in an infant or child - Vancomycin + third-generation cephalosporin (except cefoperazone)
Neonates - Ampicillin + third-generation cephalosporin (except cefoperazone)
Cefoperazone (Cefobid) is contraindicated because it may cause clotting impairment.
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum activity including gram-negative organisms; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult
1-2 g IV q12-24h
Pediatric
100 mg/kg/d IV divided q12-24h; can dilute in 1% lidocaine for IM use; not to exceed 4 g/d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, or aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin
Cefotaxime (Claforan)
Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth.
Adult
1-2 g IV q6-8h
Pediatric
50-180 mg/kg/d IV divided q4-6h
Probenecid may increase levels; coadministration with furosemide or 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 severe renal impairment; has been associated with severe colitis
Nafcillin (Nafcil, Unipen, Nallpen)
Beta-lactamase-stable antistaphylococcal agent. Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants.
Because of risk of thrombophlebitis, particularly in elderly patients, administer parenterally only for short term (1-2 d); change to oral route as clinically indicated.
Adult
2 g IV q4h
Pediatric
50-200 mg/kg/d IV divided q4-6h
Associated with warfarin resistance; effects may decrease with bacteriostatic action of tetracycline derivatives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
To optimize therapy, determine causative organisms and susceptibility; treat >10 d to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); take cultures after treatment to confirm that infection eradicated
Metronidazole (Flagyl)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa.
Adult
500 mg IV q6-12h; infuse over at least 1 h
Pediatric
15 mg/kg IV q12h; infuse over at least 1 h
Cimetidine may increase toxicity; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol
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 hepatic disease; monitor for seizures and development of peripheral neuropathy
Vancomycin (Vancocin)
Indicated for patients who cannot receive or have not responded to penicillins and cephalosporins or have infections with resistant staphylococci. Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or genitourinary procedures.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment.
Adult
1 g IV q12h; infuse over at least 1 h
Pediatric
10 mg/kg IV q6h; infuse over at least 1 h
Erythema, histamine-like 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 of neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity, first trimester of pregnancy
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, neutropenia; red man syndrome is caused by too rapid IV infusion (ie, dose given over a few minutes) but rarely happens when dose given as 2-hour infusion or PO or IP; red man syndrome is not an allergic reaction
Ampicillin (Principen)
Third-generation penicillin with bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Adult
150-200 mg/kg/d IV divided q3-4h
Pediatric
50-200 mg/kg/d IV divided q6h
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
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 renal failure; evaluate rash and differentiate from hypersensitivity reaction
More on Subdural Empyema |
| Overview: Subdural Empyema |
| Differential Diagnoses & Workup: Subdural Empyema |
 Treatment & Medication: Subdural Empyema |
| Follow-up: Subdural Empyema |
| Multimedia: Subdural Empyema |
| References |
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References
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Foerster BR, Thurnher MM, Malani PN, Petrou M, Carets-Zumelzu F, Sundgren PC. Intracranial infections: clinical and imaging characteristics. Acta Radiologica. October 2007;48(8):875-93. [Medline].
Hall WA, Truwit CL. The surgical management of infections involving the cerebrum. Neurosurgery. February 2008;62 Supplement 2:519-30. [Medline].
Krauss WE, McCormick PC. Infections of the dural spaces. Neurosurg Clin N Am. Apr 1992;3(2):421-33. [Medline].
Mauser HW, Van Houwelingen HC, Tulleken CA. Factors affecting the outcome in subdural empyema. J Neurol Neurosurg Psychiatry. Sep 1987;50(9):1136-41. [Medline].
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Further Reading
Keywords
subdural empyema, circumscript meningitis, cortical abscess, pachymeningitis interna, phlegmonous meningitis, purulent pachymeningitis, subdural abscess, SE, focal intracranial infections
