eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Epidural Abscess: Treatment & Medication

Author: Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
Coauthor(s): Aadia Rana, MD, Research Fellow, Department of Medicine, Division of Infectious Diseases, The Miriam Hospital, Brown University School of Medicine; Gopala K Yadavalli, MD, Associate Program Director of Internal Medicine, Assistant Professor of Medicine, Division of Infectious Diseases, Case Western Reserve University School of Medicine and Louis Stokes Cleveland Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Apr 20, 2009

Treatment

Medical Care

Spinal epidural abscess

A combined medical-surgical approach, with emergent surgical decompression and drainage of purulent material, has been the traditional approach to spinal epidural abscess. Antibiotic-based therapy, sometimes combined with CT-directed needle aspiration, has traditionally been used only in patients who are determined to be at prohibitively high risk of surgery or who have a fixed paralysis that lasts more than 72 hours and that is presumed to be irreversible.

Wider use of the antibiotic-based therapy for spinal epidural abscess has been advocated,^11,12 condemned,^13,14 and cautiously discussed.^8,15 The current literature on the subject consists largely of small case series and is inadequate to resolve the controversy.^1,2

If medical therapy is to be used as initial therapy for spinal epidural abscess and surgery held in reserve, a number of caveats apply, as follows:

• The patient should have no neurological deficits.
• A culture-proven microbiological diagnosis should be available (from blood culture or aspiration).
• Stringent follow-up by both the primary team and neurosurgeons must be available and emergent surgery available, if needed.  
• The physicians caring for the patient must be aware that rapid deterioration may occur at any time (the first 72 hours being most risky) and that even prompt rescue surgery may leave the patient with a neurological deficit that might have been avoided with surgery at first diagnosis.  
• A follow-up MRI is necessary within 2-4 weeks to evaluate for improvement with medical therapy.

Empirical antibiotic therapy should include coverage of gram-positive cocci, particularly staphylococci (including MRSA), and gram-negative bacilli. Vancomycin has been the standard agent for gram-positive infections, although linezolid, daptomycin, or tigecycline could be considered. The third- and fourth-generation cephalosporins and meropenem offer excellent gram-positive (except MRSA) and gram-negative coverage in addition to CNS penetration. Additional coverage may be needed if some of the less-common etiologic agents (see Causes) are suspected. Always tailor coverage once culture data are available; for example, nafcillin is a much better drug for MSSA infections than vancomycin.

Intracranial epidural abscess

A combined medical-surgical approach is used for intracranial epidural abscess. A craniotomy is usually performed. Empiric antibiotic therapy is similar to that described for spinal epidural abscess; since many of these infections result from prior interventions, the possibility of more-resistant nosocomial organisms must be considered. Vancomycin plus cefepime or meropenem would be good starting choices, with metronidazole added to the cefepime if anaerobes are a major concern.

Surgical Care

• Prompt decompression is used to manage intracranial epidural abscess, as it is uniformly considered a neurosurgical emergency.
• As discussed in detail above, most patients with spinal epidural abscess require urgent decompressive laminectomy; other surgical techniques may be preferred in certain situations.¹⁶ In some patients without neurologic deficits, medical therapy might be cautiously attempted, recognizing that disastrous outcomes may ensue from this conservative approach (see Medical Therapy). CT-guided drainage might be helpful in some cases of posterior spinal epidural abscess, but the literature on this is scant.

Consultations

Emergent consultation with a neurosurgeon is mandatory for surgical decompression and drainage of purulent material in patients with intracranial epidural abscess. Emergent surgical intervention is needed in most patients with spinal epidural abscess, and prompt consultation and tight follow-up are mandatory in those in whom surgery is deferred (see Treatment). Consultation with an infectious disease specialist is strongly recommended for both diagnostic and therapeutic assistance.

Medication

The course of medication therapy is not well defined, but 4-12 weeks is generally considered adequate. Concomitant osteomyelitis requires a 6- to 12-week course. A transition to highly bioavailable oral agents might be appropriate in some cases. Rely on an infectious disease specialist consultant for guidance. (See Medical Treatment for empiric selections.)

Antibiotics

Empiric antimicrobial therapy must be comprehensive and cover all likely pathogens. Antibiotic combinations, usually vancomycin or another MRSA agent plus a broad gram-negative agent, are recommended in both intracranial epidural abscess and spinal epidural abscess while awaiting culture data. This approach ensures coverage for a broad range of organisms and polymicrobial infections. Once organisms and sensitivities are known, antibiotic monotherapy is recommended.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with fair gram-negative and gram-positive activity. Superior CNS penetration. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Does not cover MRSA, Pseudomonas species, or resistant nosocomial enterics.

Ceftazidime (Ceptaz, Fortaz)

Third-generation cephalosporin with broad-spectrum, gram-negative activity (including Pseudomonas species). Poor efficacy against gram-positive organisms and some resistant gram-negative organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Meropenem (Merrem IV)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria, with excellent CNS penetration. Has slightly increased activity against gram-negative bacteria and slightly decreased activity against staphylococci and streptococci compared with imipenem, but much less likely than imipenem to cause seizures.

Metronidazole (Flagyl, Protostat)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Not active against any aerobes. Must be used in combination for most bacterial infections.

Vancomycin (Lyphocin, Vancocin)

Potent antibiotic directed against most gram-positive organisms and active against most Enterococcus species. Indicated in patients who cannot receive or have failed to respond to penicillins and cephalosporins or who have infections with MRSA or another susceptible gram-positive organism.

Nafcillin (Nafcil, Unipen)

A penicillin used almost exclusively for MSSA. Is not effective against MRSA infections. Do not use empirically when MRSA infection is possible.

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